headspace Dandenong & Hastings Referral Form - For Self, Family or Friends

This form will take approximately 9 minutes to complete.

If you need help understanding or completing this form and English is not your fluent language, you can contact an interpreter through the Translating and Interpreting Service (TIS) on 131 450. When you call, mention the provider number C037254 or simply say "headspace Dandenong" for assistance with the form. The service is free of cost to use.

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: *

Preferred name:

Gender and preferred pronouns:

Date of birth:

Contact number: *

Address:

Street address

City

State

Postcode

What is the best way for us to get in contact (e.g. call Mum, call after school, text first etc.)

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

If under 16 are your parents / carers aware of this referral?

YesNoNot applicable

Do you currently have support from any other organisation? If yes please list details:

Emergency Contact / Next of Kin details (must be over 18):

Referrer Information

Full name:

Relationship to young person:

Contact number:

Email:

Headspace is a voluntary service for young people aged 12 to 25. Have you got permission from the young person to make this referral?

YesNo

If you feel comfortable to, please tell us what are the main issues you are seeking help for:

Did you have someone assisting you to fill out this form?

YesNo

EACH programs - headspace Dandenong & headspace Hasings will collect personal information from you (such as your personal, family and contact details) so we can provide you with quality care. We need your permission to collect and keep your personal information.

Link to relevant EACH brochure:

Protecting your privacy - https://www.each.com.au/about-us/policies-and-statements/rights-and-responsibilities/
Complaints & Feedback - https://www.each.com.au/about-us/policies-and-statements/complaints-and-feedback/

Consent to collect & store personal information

Consent to collect & store your personal information (please tick)

I understand that my personal information will be collected and stored in accordance with the Privacy and Data Protection Act 2014 (VIC) and the Health Records Act 2001 (VIC).
*

I understand that I do not have to give EACH/headspace Dandenong & headspace Hastings any information about myself. I also understand that if I don't, EACH may not be able to give me the care that I need. *

I understand that I can withdraw or change my consent at any time. *