IMPORTANT INFORMATION ABOUT YOUR REFERRAL - PLEASE READ

headspace is a service for young people aged 12-25, providing free, youth friendly and confidential service. We can only engage with young people who have provided consent to the referral. headspace Whyalla is not a crisis service, and should you have any concerns, if the young person is in crisis, or if they are at an acute risk of harming themselves or others, please contact emergency services on 000. In a mental health emergency please contact Mental Health Triage on 131465. Please note the receipt of the referral form does not indicate acceptance to headspace Whyalla services. Suitability of the referral will be determined following assessment with the young person. Waitlist- given the demand for headspace services, there may be a waitlist at times. You will be advised by a headspace staff member via phone call or letter. We request that you seek urgent help from your

Young Person Details

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

Referrer Details

Who is your current GP?

Referral details

Risk Factors (self / referrer to complete)

Please check the appropriate boxes below
YesNo
Present in last 3 months
Past issue
YesNo
Present in last 3 months
Past issue
YesNo
Present in last 3 months
Past issue
YesNo
Present in last 3 months
Past issue
YesNo
Present in last 3 months
Past issue
If selected “yes” to suicidal behaviour or hospital presentation in last 3 months, please contact headspace Whyalla on 86414330 to discuss referral

Young Person Supports & Consent

X