headspace Professional Referral STOP - Referring yourself or a friend/family member? Please use the Self Referral Form.This form is designed for you to refer a client/patient to headspace Launceston or headspace Devonport.Please note: headspace Launceston and headspace Devonport are not acute mental health services or crisis services. If you have concerns for a person's immediate safety please contact the Mental Health Helpline on 1800 332 388. For urgent medical assistance please call: 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. Has your client/patient read and agreed with the headspace 'Just between us' confidentiality statement? (Link Above)*Yes Is this referral to headspace Launceston, headspace Devonport or headspace Burnie?*LauncestonDevonportBurnieYoung Person Details First Name:* Last Name:* Gender:* Date of birth:* Street Address:* Town/Suburb:* Postcode:* Home Phone: Mobile Phone:* Email: Which contact(s) would you prefer us to use? (you can select more than one)*EmailMobile PhoneHome PhoneVoicemailLetter Who should we contact to make an appointment? *Young PersonReferrerFamily Member Is the young person Aboriginal/Torres Strait Islander? *YesNoBoth Do they require an Interpreter? *YesNo Preferred Language:* Does the young person have a current Mental Health Care Plan?*YesNo Is the young person aware of this referral? *YesNo We are unable to make contact with them if the answer is NO.Referrer Details Your Name:* Your Organisation:* Your Role:* Do you require a copy of this referral for your records?*YesNo Your Email:* Will you or another organisation have continued contact with the young person? *YesNoOther Supports/Organisations Is there a family member or worker you would like us to speak to? *YesNo Their Name:* Their Phone:* Their Relationship to young person:* If under 16 are the young person's parents/carers aware of this referral? *YesNoOver 16 Is the young person working with any other organisations? *YesNo Details* Does the young person have an NDIS Plan? *YesNoEmergency Contact/Next of kin - MUST BE OVER 18 Name:* Relationship to young person:* Phone:*Medicare/Centrelink: Do you know the young persons Medicare Details? *YesNo Medicare Card Number* Line Number* Medicare Expiry Date:* Does the young person have a regular Doctor?*YesNo Doctor's Name:* Medical Practice:* Does the young person have a Health Care Card or Pension Card?*YesNo Centrelink Reference Number: (if known) Expiry Date: (if known)Reason For Referral Please list the main reasons for referral:* Please attach any relevant assessments/information Are there any general health issues limiting the young persons day to day or social activities?*YesNo Are drugs and/or alcohol having a negative impact on areas of the young person's health or lifestyle? *YesNo Does the young person require support with education, training and/or employment?*YesNoSubmitReset
