headspace Dandenong & Hastings - service provider referral form

headspace Dandenong & Hastings Service Provider Referral Form - for professionals working with young people

Note: headspace is not an acute mental health service or crisis service. If you have concerns for a person's immediate safety, please contact:

For urgent medical assistance please call: 000

Psychiatric Triage Service (Monash catchment): 1300 369 012

Peninsula Triage (Peninsula catchment): 1300 792 977

Young Person Details

First Name *

Last Name *

Date of Birth *

Contact Number: *

Unit / Apartment Number

Street Number *

Street Name *

Suburb *

State *

Postcode *

Alternative contact details (e.g. name of parent, contact numbers)

Email of young person

Preferred Contact Method

Who should be contacted to make an appointment

Gender Identity *

Note: Record of client's current gender identity. This may be different from the sex assigned at birth or listed on legal documents. When in doubt, ask: How do you describe your gender?

Pronouns *

If other, please advise

Note: Using correct pronouns is a basic sign of respect. If unsure, ask: 'Which pronouns should we use when referring to you?'

Are there any communication needs that we need to consider? (e.g. interpreter, Auslan, other factors, etc.)

Does the young person identify as Aboriginal or Torres Strait Islander?

Medicare information if known (Number + (IRN) Individual Reference Number + Expiry)

Referrer Information

Referrer First Name *

Referrer Last Name *

Role

Organisation

Referrer contact number *

Email

Preferred contact method (e.g. email, mobile, specific times to call, etc)

Please indicate the primary areas of support this young person requires (select all that apply)

Note: Please note that access to Work and Study Support requires the young person to also be engaged with a clinician. Standalone access to Work and Study Support is not available.

Reason for Referral: Briefly describe the key issues or concerns leading to this referral. *

If there is risk, has a safety plan been done? If so, what are the details?

Please provide us with any other relevant background information:

Are there any other services or supports involved (e.g. NDIS)? If yes, please provide details:

Does the young person have a Mental Health Treatment / Care Plan?

Please attach any additional relevant documents here:

Browse

Note: If referring from a Tertiary Mental Health service (e.g. Monash Health), please include a Discharge Summary or full Formulation document.

Collection and Use of Personal Information

I have discussed the proposed referral with the young person, parent or guardian, and I am satisfied that they understand that their information will be collected and stored by Each in order to provide care.

I agree *

If you would like to save and print a copy of your Referral Form before submitting please follow the steps below:

Select the 3-dot icon in your browser, top right corner and select print.
Printer, select Save as PDF
Pages, select All
Select Save and Print your referral