headspace Whyalla Referral Form - Staff Completed

headspace Whyalla
Referral Form - Staff Completed

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

Young Person Details

Full name *

Preferred name

Previous Client?
Yes
No

Date of Birth *

Gender

Preferred Pronouns

Mobile *

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

Your email

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

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

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

Who is your current GP?

Name of GP

Surgery Name

Phone

Do you/does the person have a Mental Health Treatment Plan?

Referral details

What are the current issues? (please include information about the duration, age of onset and pre-existing diagnoses) Please attach further information/relevant assessments, reports etc. in the 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
Work and Study Support
Sexual Health Support
Drug and Alcohol Support

Risk Factors (self / referrer to complete)

Please check the appropriate boxes below

Suicidal thoughts

Yes No

Present in last 3 months
YesPresent in last 3 months Yes
NoPresent in last 3 months No
Past issue
YesPast issue Yes
NoPast issue No

	Yes	No
Present in last 3 months	YesPresent in last 3 months Yes	NoPresent in last 3 months No
Past issue	YesPast issue Yes	NoPast issue No

Suicidal behaviour

Yes No

Present in last 3 months
YesPresent in last 3 months Yes
NoPresent in last 3 months No
Past issue
YesPast issue Yes
NoPast issue No

	Yes	No
Present in last 3 months	YesPresent in last 3 months Yes	NoPresent in last 3 months No
Past issue	YesPast issue Yes	NoPast issue No

Deliberate Self harm

Yes No

Present in last 3 months
YesPresent in last 3 months Yes
NoPresent in last 3 months No
Past issue
YesPast issue Yes
NoPast issue No

	Yes	No
Present in last 3 months	YesPresent in last 3 months Yes	NoPresent in last 3 months No
Past issue	YesPast issue Yes	NoPast issue No

Harm to others

Yes No

Present in last 3 months
YesPresent in last 3 months Yes
NoPresent in last 3 months No
Past issue
YesPast issue Yes
NoPast issue No

	Yes	No
Present in last 3 months	YesPresent in last 3 months Yes	NoPresent in last 3 months No
Past issue	YesPast issue Yes	NoPast issue No

Hospital presentation (for mental health concern)

Yes No

Present in last 3 months
YesPresent in last 3 months Yes
NoPresent in last 3 months No
Past issue
YesPast issue Yes
NoPast issue No

If selected “yes” to suicidal behaviour or hospital presentation in last 3 months, please contact headspace Whyalla on 86414330 to discuss referral

	Yes	No
Present in last 3 months	YesPresent in last 3 months Yes	NoPresent in last 3 months 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

Verbal consent provided
Yes

Additional Comments / Follow Up Required

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