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headspace Self Referral Launceston

headspace Launceston supports young people aged 12-25.  headspace is not a crises service.  If you require immediate support, contact Life line 13 11 14, Kids helpline 1800 551 800 or Access Mental Health Helpline 1800 332 388

We welcome contact from family and friends prior to referral who are worried about their young person but uncertain of support options Ph 6335 3100 or email headspace@csys.com.au or visit www.headspace.org.au

Have you read and agree with the headspace 'Just between us' confidentiality statement? 
Is this referral to headspace Launceston, headspace Devonport or headspace Burnie? 

Lets get started

Your Name
Date of Birth 
Have you previously been known as another name?

Where do you live

Address
Who can we contact about this referral? (tick all that apply) 
People you consent to us contacting
How would you like us to contact you during your care at headspace? (Tick all that apply) 
Can we send SMS to confirm your appointments 

Cultural Identity

What culture/s do you identify with? 
Do you require an Interpreter? 

Legal Guardian/s (for under 18)

Legal Guardians
Do you live with your Legal Guardian 

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

This person needs to be over 18. If you are under 16 this person needs to be your parent / guardian)

Same as Legal guardian referral contact - if NO please provide contact details 
Emergency Contact Name

Medicare and Centrelink Information

Medicare Expiry Date (M/Y)

Pension / Health Care Card

Pension/Health Care Card Expiry Date (M/Y)
Are you a student or visitor from another country? 

Current Support

If you are under 16 does your legal guardian / Parent know about this referral? 
Do you currently get help from any of the following services (tick all that apply) 
Do you have a current mental health care plan? 
Do you have an NDIS Plan? 
Do you have a General Practitioner?  

Reason for Referral

What areas would you like support with (you can pick more than one) 

In your own words tell us why you would like to speak to someone at headspace. This could include what you need support for, how you are feeling or what you are challenged by?

Privacy, confidentiality and how we use your information. Please read and sign or tick the Just between us statement.

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.

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.

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.

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.