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headspace Service Provider/Family & Friends Referral Form

 

headspace is a mild to moderate early intervention service for young people aged 12-25 years. Referrals outside of this scope will not be accepted.  If you have any questions about a potential referral, please contact our office and we can support you through the referral process.

 

 

This form is designed to refer a young person to headspace Launceston, headspace Devonport or headspace Burnie.

Please note: headspace is not an acute mental health service. If you have any immediate concerns for the safety of a young person, headspace is not an appropriate referral. Please call Access Mental Health on 1800 332 388, direct the young person to the emergency department or call triple 000.

Privacy is important to us. This info will be kept confidential and used only to provide the best care possible. Please read the headspace 'Just between us' confidentiality statement.

Do you have any immediate concerns about the safety of the young person or others? 

headspace is not an acute mental health service. If you have any immediate concerns for the safety of a young person, headspace is not an appropriate referral. Please call Access Mental Health on 1800 332 388, direct the young person to the emergency department or call triple 000.

Before you proceed with this referral. 
Is the young person aware of this referral? 
Is this referral to headspace Launceston, headspace Devonport or headspace Burnie? 

Young Person's Details

Young Person's Name
Has the young person previously been known as another name?
Date of Birth 
Young Person's Home Address
Can we contact the young person about this referral? 
What is the best way to contact the young person?
Can we use SMS to confirm their appointments?
Can we send mail to their home address?

Who to contact about this referral

We are unable to make contact with them if the answer is NO.

Cultural Identity

What culture does the young person identify with? 
Does the young person require an interpreter?

Some Medical & Centrelink information (if known)

Medicare Expiry Date
Does the young person have a regular doctor? 
Does the young person have a current Mental Health Care Plan? 
Does the young person have an NDIS Plan? 
Does the young person have a Health Care Card or Pension Card? 
Card Expiry Date

Referrer Details

Emergency Contact/Next of Kin (MUST BE OVER 18)

Emergency contact details are the same as referrer above
Does the young person consent to headspace contacting the above-named person if unable to contact the young person about this referral?
If under 16 are the young person's parents/carers aware of this referral? 

Other Supports/Organisations

Does the young person currently see any other services? If yes, please tick the appropriate box
Are they under any legal or guardianship orders?

Reason For Referral

What kind of support do they require? You can pick more than one. 

Referrer Information

What happens next?

We will contact you within 2 working days to chat to you about your referral. Please add our phone number 03 6408 0251 into your contacts so you know who is calling you. If we are not able to get in contact with you we will follow up for a maximum of two attempts via phone call, SMS or Email. If you consent we may also attempt to contact your other preferred contacts.

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Cornerstone Youth Services acknowledges and pays respect to the Tasmanian Aboriginal Community as the traditional and original owners, and continuing custodians of this land on which we gather today and acknowledge Elders – past and present.