headspace Self Referral | Cornerstone Youth Services

STOP - Professional referrer? Please use the Professional Referral Form

This form is designed for you to refer yourself, a friend or family member to headspace Launceston or Devonport.

Please note: headspace Launceston and headspace Devonport are not acute mental health services or crisis services. If you have concerns for your own or someone's immediate safety please contact the Mental Health Helpline on 1800 332 388. For urgent medical assistance please call: 000.

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

Have you read and agree with the headspace 'Just between us' confidentiality statement? (link above)*

Yes

Is this referral to headspace Launceston, headspace Devonport or headspace Burnie?*

Launceston

Devonport

Burnie

Young Person Details:

First Name: *

Last Name: *

Gender:*

Date of Birth: *

Address Line 1:*

Address Line 2:

Suburb:*

Postcode:*

Mobile Phone:

Home Phone:

Email:*

Preferred language: *

Medical and Centrelink information (if known)

Medicare Card Number

Medicare Reference Number

Medicare Expiry Date

Does the young person have a regular doctor? *

Yes

Name:*

Medical Practice*

Does the young person have a Health Care Card or Pension Card? *

Yes

Centrelink Reference number:*

Card Expiry Date*

Are you referring yourself or somebody else? *

Myself

Somebody Else

What is your name?*

Relationship to Young Person? *

Phone Number:*

Your Email:*

Does the young person know about and consent to this referral?*

Yes

PLEASE NOTE WE ARE UNABLE TO MAKE CONTACT WITH THEM IF THEY ARE NOT AWARE OF THIS REFERRAL.