headspace service provider referral This form is for referrals from professionals, schools and community agencies. Privacy is important to us, the information on this form will be kept confidential in line with headspace and Stride policies. headspace Privacy Policy:https://headspace.org.au/privacy-policy/ Stride Privacy Policy and Statement:https://stride.com.au/privacy-policy/ Note: If you are a young person or the family or friend of a young person looking to refer to headspace please click here. "*" indicates required fields Referrer detailsReferrer First Name* Referrer Last Name* Referrer Phone Number* Referrer Email Address Referring Organisation* Referrer Job Title/Role* Young person's detailsSelect which centre*Please select your headspace centreheadspace Townsvilleheadspace Geelongheadspace Ocean Groveheadspace Corioheadspace Mirandaheadspace HurstvilleDoes the young person consent to the referral to headspace?* Yes No First Name* Last Name* Preferred Name Pronouns*They/ThemHe/HimShe/HerGender* Male Female Non Binary Intersex Transgender and/or gender diverse Other Prefer not to say Date of birth* DD slash MM slash YYYY Birth CountryPlease select…AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsPreferred language*Please select…EnglishArabicAfrikaansAuslanBosnianCantoneseCroatianDariDutchFrenchGermanGreekGujaratiHazaraghiHindiHungarianIndonesianItalianJapaneseKarenKarenniKurdishMacedonianMandarinMalayalamMaltesePersianPolishPortuguesePunjabiRussianSerbianSpanishSinhaleseSwahiliTagalog/FilipinoTamilTeluguThaiTurkishUkrainianUrduVietnameseOtherIs an interpreter required? Yes No Is the young person Aboriginal or Torres Strait Islander?* Yes, I’m Aboriginal Yes, I’m Torres Strait Islander Yes, I’m Both Aboriginal and Torres Strait Islander No Unsure Prefer not to say Young Person's Contact DetailsStreet Address* Suburb Postcode* Is it okay to send relevant mail to this address? Yes No Unsure Phone Number* Email Address Contact preference Phone Call SMS Email Emergency Contact Details for Young PersonEmergency Contact Name* Emergency Contact Number* Their relationship to the young person Further InformationPresenting Issues(please tick all that apply) Feeling down or stressed Wanting to see a GP Sexual health (including contraception and sexual health checks) Support with work or study Alcohol or other drugs negatively impacting your life Relationship issues Troubles with family or friends Want to talk about sexuality or gender identity Issues with bullying and or harassment Physical health issues Issues with self-harm Body image or eating Other Please add any further information that will support our engagement and service planning process:Please attach copy of current Mental Health Treatment Plan if available Drop files here or Select files Max. file size: 5 MB. Please attach any other supporting documents that may be relevant Drop files here or Select files Max. file size: 5 MB. Would the young person like to involve a family member or support person in the next steps of connecting with headspace?* Yes No Maybe Please note that headspace is not an emergency service. For mental health emergencies please contact your local health service or call 000.CAPTCHACommentsThis field is for validation purposes and should be left unchanged.
