Office Use Only

Young Person Details

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.

Client’s Key Contact Person (in case of emergency)

Referrer Details

GP Details

Referral details

Click or drag files to this area to upload. You can upload up to 5 files.

Risk Factors (self / referrer to complete)

Please check the appropriate boxes below
YesNo
Present in last 4 weeks
Yes
No
Past issue
Yes
No
YesNo
Present in last 4 weeks
Yes
No
Past issue
Yes
No
YesNo
Present in last 4 weeks
Yes
No
Past issue
Yes
No
YesNo
Present in last 4 weeks
Yes
No
Past issue
Yes
No
YesNo
Present in last 4 weeks
Yes
No
Past issue
Yes
No
If selected “yes” to suicidal behaviour or hospital presentation in last four weeks, please contact headspace Port Augusta on 8641 4300 to discuss referral.

Young Person Supports & Consent

Clear Signature
Clear Signature
Clear Signature

X