headspace First Contact Information Form Joondalup

Today's date:

Completed by (name):

YOUNG PERSON'S DETAILS

Full name:

Preferred name:

Date of birth (DD/MM/YYYY):

Age:

Mobile:

Email:

Preferred pronouns:

Gender identity:

Living arrangements:

Who would you prefer we contact about your appointments?

My parent/carer

Do you have any allergies?

Yes (Please specify):Yes (Please specify):

Address:

City

State

Post Code

Other Details

Are you of Aboriginal or Torres Straight Islander origin?

Yes, Aboriginal

Yes, Torres Strait Islander

Yes, both Aboriginal and Torres Strait Islander

Prefer not to say

Country of birth:

Preferred language:

Language spoken at home (if other than English):

Do you require an interpreter for you or your parents?

Yes

Have you previously been diagnosed with a mental health condition?

Yes (please specify)Yes (please specify)

Emergency Contact Details

Full name:

Phone number:

Relationship to young person:

Address:

City

State

Post Code

GP Contact Details

Name:

Practice name:

Do you consent to us contacting your GP regarding your care at headspace?

Yes

Reminders

SMS Text Service As part of our ongoing service and commitment to you, we have an SMS service which allows us to send you appointment reminders by text. If you would like to receive a reminder SMS the day before your appointment please fill in the below. If you would not like us to do this please tick the appropriate box:

Would you like to receive SMS reminders?

Yes, I would like to receive reminder texts for my appointments (on the mobile number given above)

No, I would not like this service at this point. I will let headspace know should this change.

Yes, on different mobile number (please specify):Yes, on different mobile number (please specify):

Contact

headspace can communicate with you by email, phone, SMS or by mail. Please let us know you preferred method of communication:

SMS

Phone

Other Supports

headspace values the independence of young people and acknowledges that family and carers can be great supports. We encourage all young people to seek support from their family. If you are aged 18 years and younger and wish to attend headspace, we need to gain consent from your parents/guardians.

If the above is relevant to you, please indicate: Is a parent / carer / guardian aware that you have contacted us?

N/A - I am 18 years or over

Yes - Please specify who is awareYes - Please specify who is aware

Name of parent / carer / guardian (if present)Name of parent / carer / guardian (if present)

Authorisation of parent / carer / guardian (if present)Authorisation of parent / carer / guardian (if present)

No, they are not awareNo, they are not aware

If you answered No to the question above, please choose in which circumstances you are happy from us to contact them:

N/A

Only in an emergency.

To advise I am attending headspace, information about the process, but no content of the session

To advise I am attending headspace, information about the process, including content of the session

To book appointments on my behalf.

If you are human, leave this field blank.