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Please enable JavaScript in your browser to complete this form.Office Use OnlyDate of ReferralStaff Name *Eligible for headspace services?Choice 4YesNoUndeterminedRationaleAppointment Date / TimeDateTimeYoung Person DetailsFull name *Preferred namePrevious Client?YesNoDate of Birth *DD12345678910111213141516171819202122232425262728293031MM123456789101112YYYY20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920GenderPreferred PronounsMobile *Is it okay for us to contact you via SMS?YesNoYour emailIs it okay for us to contact you via Email?YesNoAddressAddress Line 1CityState / Province / RegionPostal CodeThis 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?YesNoAre you of Aboriginal or Torres Strait Islander origin? Choice 1NoAboriginalTorres Strait IslanderBothPrefer not to sayPlease provide your Cultural BackgroundClient’s Key Contact Person (in case of emergency)NamePhoneRelationship to young personReferrer DetailsIs this a self referral?Choice 3YesNoName of Referrer (if NOT self-referral)Referrer PhoneReferrer FaxReferrer EmailOrganisationRelationship to Young PersonWho is your current GP?Name of GPSurgery NamePhoneDo you/does the person have a Mental Health Treatment Plan?Choice 3YesNoReferral detailsWhat 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 SupportWork and Study SupportSexual Health SupportDrug and Alcohol SupportRisk Factors (self / referrer to complete)Please check the appropriate boxes belowSuicidal thoughts YesNo Present in last 3 monthsYesPresent in last 3 months YesNoPresent in last 3 months NoPast issueYesPast issue YesNoPast issue No Suicidal behaviour YesNo Present in last 3 monthsYesPresent in last 3 months YesNoPresent in last 3 months NoPast issueYesPast issue YesNoPast issue No Deliberate Self harm YesNo Present in last 3 monthsYesPresent in last 3 months YesNoPresent in last 3 months NoPast issueYesPast issue YesNoPast issue No Harm to others YesNo Present in last 3 monthsYesPresent in last 3 months YesNoPresent in last 3 months NoPast issueYesPast issue YesNoPast issue No Hospital presentation (for mental health concern) YesNo Present in last 3 monthsYesPresent in last 3 months YesNoPresent in last 3 months NoPast issueYesPast issue YesNoPast issue No If selected “yes” to suicidal behaviour or hospital presentation in last 3 months, please contact headspace Whyalla on 86414330 to discuss referralYoung Person Supports & ConsentDoes young person consent to referral?YesNoIf under 16 do carers consent to referral?YesNoDoes the young person receive support from other agencies?YesNoDoes the young person consent to sharing information with these services?YesNoDoes the young person consent to sharing information with referrer and other agencies to ensure appropriate care?YesNoAgencies:Caregiver 1 NameCaregiver 1 Signature Clear Signature Caregiver 2 NameCaregiver 2 Signature Clear Signature Young Person Signature Clear Signature Verbal consent providedYesAdditional Comments / Follow Up RequiredMessageSubmit