headspace client consent form

If you need assistance with this form from your parent/guardian please ensure they are with you to complete and submit
If you have any questions about this consent form please discuss with your worker during your appointment
This service is only available within South Australia. Check our services page for specific locations. Or contact Head to Health directly on 1800 595 212 or visit website www.headtohealth.gov.au for alternative services in their area.

Consent for Support

• I consent for headspace clinicians and support workers to provide support to me, which may include a range of assessments, interventions and support services.
• I understand that the service is voluntary and consent is valid while I am a current client with headspace. I understand I can change or withdraw my consent at any time.
• I understand headspace does not provide emergency services or after hours care.
• I understand my details will remain confidential, unless there is a serious risk of me harming myself, harming others or if a crime has been committed.
• I understand that all information collected by headspace will be treated in a confidential manner and stored securely.

Consent to exchange information

Consent to Email and SMS

Although unlikely, SMS and email may be intercepted and read by people it is not intended for.
I understand headspace cannot guarantee the security and confidentiality of SMS and Email and I consent to communication via:


Sign here using your mouse
Sign here using your mouse

**This consent form is valid for 12 months