Client 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)

Cultural Background

Spirituality / Beliefs

Referrer Details

GP Details

(Please note this is not required to access YCCC services)

Young Person Supports & Consent

Clear Signature
Clear Signature
Clear Signature

IMPORTANT INFORMATION ABOUT YOUR REFERRAL- PLEASE READ

CObH provides free and confidential services for young people aged between 12-25 years, who consent to receiving support. CObH 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 CObH team will make contact. Waitlist - given the demand for CObH services, there may be a waitlist at times. You will be advised by a CObH staff member via phone call or letter. Please seek support from your GP or local hospital should your situation change. We recommend a list of services including Beyond Blue 1300 224 636 and Lifeline 13 11 14.

Reason for Referral

(What are the current issues and what support do you need? Please include info about the duration, age of onset and pre-existing diagnoses. Please attach further information/relevant assessments, reports etc.)
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 4 weeks
Yes
No
Past issue
Yes
No
YesNo
Present in last 4 weeks
Yes
No
Past issue
Yes
No
YesNo
Present in last 4 weeks
Yes
No
Past issue
Yes
No
YesNo
Present in last 4 weeks
Yes
No
Past issue
Yes
No
YesNo
Present in last 4 weeks
Yes
No
Past issue
Yes
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.
(Please list below any current or previous medications that a client or young person has been on for the treatment/management of a mental health illness)
(Please list below any current or previous medications that a client or young person has been on for the treatment/management of a mental health illness)

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