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

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

Who is your current GP?

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)
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 3 months
Yes
No
Past issue
Yes
No
YesNo
Present in last 3 months
Yes
No
Past issue
Yes
No
YesNo
Present in last 3 months
Yes
No
Past issue
Yes
No
YesNo
Present in last 3 months
Yes
No
Past issue
Yes
No
YesNo
Present in last 3 months
Yes
No
Past issue
Yes
No

Young Person Supports & Consent

Free and confidential services for young people aged between 12-25 years, who consent to receiving support. headspace is not a crisis service, if the young person is in crisis or are at acute risk of harming themselves or others, please contact emergency services on 000. In a mental health emergency please contact Mental Health Triage on 13 14 65 (16+ years) or Kids Helpline 1800 55 1800. Once a referral form has been received the headspace team will contact you.
Clear Signature
Clear Signature
Clear Signature

X