headspace Port Augusta Referral Form - Staff Completed

headspace Port Augusta
Referral Form

Please complete all information required in the form fields below

Office Use Only

Date of Referral *

Staff Name *

Eligible for headspace services?

Rationale

Appointment Date & Time
Date
Time

Worker

Young Person Details

Full name *

Preferred name

Previous Client?
Yes
No

Date of Birth *

Age

Gender

Preferred Pronouns

Address *
Address Line 1
City
State / Province / Region
Postal Code
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.

Is it okay for us to send headspace branded documents to this address?
Yes
No

Mobile Phone *

Is it okay for us to contact you via SMS?
Yes
No

Email Address

Is it okay for us to contact you via Email?
Yes
No

Are you of Aboriginal or Torres Strait Islander origin?

Please provide your Cultural Background

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

Name

Phone

Relationship to young person

Referrer Details

Is this a self referral?

Name of Referrer (if NOT self-referral)

Referrer Phone

Referrer Fax

Referrer Email

Relationship to Young Person

GP Details

Does the young person have an existing GP?

Does the young person have a Mental Health Treatment Plan?

Referral details

Reason for Referral (What are the current issues? Please include info about the duration, age of onset and pre-existing diagnoses. Please attach further information/relevant assessments, reports etc. in box below)

Please upload further information/relevant assessments, reports etc.

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

What has been the impact of these issues? (e.g. relationships, school, work, home etc.)

Which headspace program are you referring to?
Mental Health Support
Vocational Support (IPS)
Port Pirie Outreach

Risk Factors (self / referrer to complete)

Please check the appropriate boxes below

Suicidal thoughts

Yes No

Present in last 4 weeks
YesPresent in last 4 weeks Yes
NoPresent in last 4 weeks No
Past issue
YesPast issue Yes
NoPast issue No

	Yes	No
Present in last 4 weeks	YesPresent in last 4 weeks Yes	NoPresent in last 4 weeks No
Past issue	YesPast issue Yes	NoPast issue No

Suicidal behaviour

Yes No

Present in last 4 weeks
YesPresent in last 4 weeks Yes
NoPresent in last 4 weeks No
Past issue
YesPast issue Yes
NoPast issue No

	Yes	No
Present in last 4 weeks	YesPresent in last 4 weeks Yes	NoPresent in last 4 weeks No
Past issue	YesPast issue Yes	NoPast issue No

Deliberate Self harm

Yes No

Present in last 4 weeks
YesPresent in last 4 weeks Yes
NoPresent in last 4 weeks No
Past issue
YesPast issue Yes
NoPast issue No

	Yes	No
Present in last 4 weeks	YesPresent in last 4 weeks Yes	NoPresent in last 4 weeks No
Past issue	YesPast issue Yes	NoPast issue No

Harm to others

Yes No

Present in last 4 weeks
YesPresent in last 4 weeks Yes
NoPresent in last 4 weeks No
Past issue
YesPast issue Yes
NoPast issue No

	Yes	No
Present in last 4 weeks	YesPresent in last 4 weeks Yes	NoPresent in last 4 weeks No
Past issue	YesPast issue Yes	NoPast issue No

Hospital presentation (for mental health concern)

Yes No

Present in last 4 weeks
YesPresent in last 4 weeks Yes
NoPresent in last 4 weeks No
Past issue
YesPast issue Yes
NoPast issue 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.

	Yes	No
Present in last 4 weeks	YesPresent in last 4 weeks Yes	NoPresent in last 4 weeks No
Past issue	YesPast issue Yes	NoPast issue No

Young Person Supports & Consent

Does young person consent to referral?

If under 16 do carers consent to referral?

Does the young person receive support from other agencies?

Does the young person consent to sharing information with these services?

Does the young person consent to sharing information with referrer and other agencies to ensure appropriate care?

Agencies:

Caregiver 1 Name

Caregiver 1 Signature

Clear Signature

Caregiver 2 Name

Caregiver 2 Signature

Clear Signature

Young Person Signature

Clear Signature

Phone