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Privacy is important to us, the information on this form will be kept confidential in line with headspace and Stride policies.
Note: If you are a young person or the family or friend of a young person looking to refer to headspace please click here.
This information is about the young person who is attending headspace today. Please complete as much as you can.
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headspace would like to acknowledge Aboriginal and Torres Strait Islander peoples as Australia’s First People and Traditional Custodians. We value their cultures, identities, and continuing connection to country, waters, kin and community. We pay our respects to Elders past and present and are committed to making a positive contribution to the wellbeing of Aboriginal and Torres Strait Islander young people, by providing services that are welcoming, safe, culturally appropriate and inclusive.
headspace is committed to embracing diversity and eliminating all forms of discrimination in the provision of health services. headspace welcomes all people irrespective of ethnicity, lifestyle choice, faith, sexual orientation and gender identity.
headspace Beauesert, Geelong, Hurstville, Ipswich, Meadowbrook, Miranda, Nundah, Townsville and Woolloongabba are operated by Stride.
headspace National Youth Mental Health Foundation is funded by the Australian Government Department of Health.
