headspace self referral form

This form is for young people (12-25 years old) to fill out, or for family and friends to fill out on their behalf, to request support from headspace.

These forms are checked once per workday (Monday-Friday, between the hours of 9am-5pm), if you need immediate support please contact Lifeline on 13 11 14 or if it’s an emergency call 000.

Your privacy is important to us, the information on this form will be kept confidential in line with headspace privacy policy and Stride privacy policy.

If you would prefer to complete a referral over the phone, please call your local headspace centre.

Note: If you are a teacher, GP, caseworker etc. please go to our professional referral form.

Request for support

Are you completing this request for yourself or on behalf of someone else?*
Is the person aware and consenting of you making this referral?*
Gender*
DD slash MM slash YYYY
Would you like an interpreter?
Are you Aboriginal or Torres Strait Islander? *

Contact Details

Is it okay to send relevant mail to this address?
How would you like us to contact you after the first phone call

Emergency Contact Details

This person will only be contacted in the case of an emergency

Further Information

Reason for contacting headspace Geelong
(please tick all that apply)
e.g. name of school attending, hours of work per week
Would you like to involve a family member or support person in the next steps of connecting with headspace?
Would you like a copy of this completed form sent to your email address?

After you submit this form you will be contacted by a team member within a week. If you have any concerns in the meantime please call your local headspace centre

Please note that headspace is not an emergency service. For mental health emergencies contact your local health service or call 000

This field is for validation purposes and should be left unchanged.