headspace Swan Hill | Family, Friend or Professional referral form

  • Family, Friend or Professional Referral Form

    Use this form if you are a family member, friend or GP/support worker/teacher etc.

  • About the young person

  • Has the young person agreed to this referral?*
  • Are they known by any other names?*
  • Date of birth*
     - -
  • Is this a referral for the young person to receive services online via our VideoCall/Telephone service?
  • Gender*

  • What are their preferred pronouns?
  • Is the young person Aboriginal or Torres Strait Islander?*
  • Interpreter required? *
  • Does the young person have literacy issues?
  • Medicare expiry date
     - -
  • Does the young person have a Health Care Card?
  • Health Care Card expiry date
     - -
  • If under 16 are their parents/carers aware of this referral?*

  • Referrer details

  • Who should headspace Swan Hill contact to make an appointment?*

  • Current/past support services

  • Does the young person receive support from other services?*
  • Has the young person received assistance from other mental health services prior to this referral?*
  • Do they have a doctor?*

  • Emergency contact

  • Reason for contacting headspace Swan Hill

    Please select the options below that match the young person's situation.

  • Please indicate the young person's preferred clinician gender (if any)*

  • Additional comments

    Is there anything else you think we should know about? Tell us more here.

  • Privacy

  • Privacy is important to us. This information will be kept confidential and used only to give you the best care possible. 

    headspace Privacy Policy 

  • I have read and I understand this privacy information*
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