Geelong headspace Updated Details Form

Personal details

First Name(s)*

As it appears on your Medicare card

Last Name(s)*

As it appears on your Medicare card

Preferred Name

Date of Birth*

Birth Sex*

Gender Identity

Pronouns*

Address*

Suburb*

Postcode*

Home Phone*

Mobile Phone*

Please write who the number belongs to?

Email*

We will send SMS/Phone reminders of your appointments, SMS messages about test results and SMS reminders about preventative health measures such as cervical screens, Care plans, assessments, and routine tests.

Medicare Card Number

Ref (Number next to your name)

Expiry Date

Do you have a health care card?

Health Care Card Number*

Expiry Date (Health Care Card)*

Do you have a pension card?

Pension Card Number*

Expiry Date (Pension Card)*

Cultural background

Country of birth

Please specify what language you speak

Allergies

Smoking

Alcohol

Secondary contacts

Next of Kin 18+years (This may be a friend or a family member) We will contact Next of Kin If we cannot get a hold of you

Name*

Relationship to you

Phone*

Address*

Suburb

Postcode*

Contact method

Health information will be on a database used across 2 headspace sites (locations Geelong & Corio) Please sign your consent to the above information

Signature*

Date*

Welcome Pack

All clients will receive a welcome pack upon booking an initial appointment and every 6 months thereafter. The welcome pack will be sent via SMS when they each time they update their personal details. This is to keep you up to date with any policy changes as well as a reminder of our policy. The welcome pack explains the client wellbeing survey hAPI, privacy & confidentiality and other resources while you wait to see a clinician at headspace.

Young person’s name

Signature

Date

Parent/guardian name

Signature

Date

headspace staff member name

Signature

Date

Services

Find a service

Who we help

What we do

Our stories

About us

About

Our mission and values

Our impact

Our team

Accreditation

Evidence and evaluation

Services

Who we help

What we do

About

Geelong headspace Updated Details Form