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?*

YesNo
Full name*

First NameLast Name
Are they known by any other names?*

YesNo
Date of birth*

DayMonthYear
Address*

Street Address

Street Address Line 2

City/townState

Postcode
Young person's phone number*
Young person's e-mail
If the young person is currently enrolled in secondary school please state which one*
Name of Secondary School if applicable.
Is this a referral for the young person to receive services online via our VideoCall/Telephone service?

YesNo
Gender*

MaleFemaleOther
What are their preferred pronouns?

Him/hisShe/herThey/themPrefer not to answer
Is the young person Aboriginal or Torres Strait Islander?*

YesNo
Country of birth
Preferred language
Interpreter required? *

YesNo
Does the young person have literacy issues?

YesNo
Medicare number
Medicare reference number
Medicare expiry date

DayMonthYear
Does the young person have a Health Care Card?

YesNo
Customer Reference Number (CRN)
Health Care Card expiry date

DayMonthYear
If under 16 are their parents/carers aware of this referral?*

YesN/ANo
Parent/carer name*
Parent/carer phone number*
Relationship to the young person*
Referrer details
Who should headspace Swan Hill contact to make an appointment?*

Young person (if aged 16 or more)ReferrerParent/carer
Referrers name*

First NameLast Name
Phone number*
Email*
Service if applicable*
Your relationship to the young person*
Current/past support services
Does the young person receive support from other services?*

YesNoNot sure
Name or description of other services
Name or description of other services
Has the young person received assistance from other mental health services prior to this referral?*

YesNoUnsure
Do they have a doctor?*

YesNoNot sure
Doctor/ Clinic Name
Doctor/clinic contact phone number
Emergency contact
Full Name*

First NameLast Name
Phone number*
Relationship *
Reason for contacting headspace Swan Hill

Please select the options below that match the young person's situation.
Physical healthFamily issuesAnxiety stressLow moodSexual healthTrauma/griefAccommodationAlcohol and drugsSelf harmThinking of suicideRelationship issuesEmployment issuesFriendship issuesSchool issuesOther
Additional comments

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headspace Swan Hill Privacy Policy
I have read and I understand this privacy information*

YesNo
Upload any relevant supporting documents (shared support plan, relevant assessments, mental health care plan etc)

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Family, Friend or Professional Referral Form

About the young person

Referrer details

Current/past support services

Emergency contact

Reason for contacting headspace Swan Hill

Additional comments

Privacy