headspace Dandenong & Hastings - service provider referral form

headspace Dandenong & Hastings service provider referral form - For professionals working with young people

Please note that 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:

Full name: *

Date of birth: *

Contact number: *

Address:

Street address

City

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 and preferred pronouns:

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

Does the young person identify as:

AboriginalTorres Straight IslanderBothNeither

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

Referrer Information

Referrer name: *

Role:

Organisation:

Referrer contact number: *

Email:

Best method to get in touch (e.g. email, mobile, specific times to call, etc)

Reason for referral to headspace: *

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?

YesNoNot sure

Please attach any additional relevant documents here:

Browse

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

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:

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