Please sign and submit the completed form to info@headspaceospk.com.au or fax to 9208 9599 
Referrals will not be accepted without the signed consent of the young person (see overleaf)

Name of young person	<PtFullName>	Date of Referral <TodaysDate>	
Gender	<PtSex>	D.O.B. <PtDoB>	
Is the young person of Aboriginal and or Torres Strait Islander descent?
<Aboriginal and or Torres Strait Islander descent?>	
Address	Street: <PtStreet>
Suburb: <PtCity>    Postcode: <PtPostcode>	
Contact Details	Mobile: <PtPhoneMob>   Home: <PtPhoneH>
Email: <PtEmail>	
Preferred contact	<Preferred contact method>	
Next of Kin/Emergency contact name	<NOKName>	Relationship: <NOKRelation>
Phone: <NOKContact>	
GP name	<DrName>	Practice Name:
<Practice>	
GP contact details	Phone: <DrPhone>	Email: <DrEmail>	
Can we contact the GP? <Can we contact the GP?>	

Referrer name
(if different to the GP)	<Referrer name (if different to GP)>	Referring Agency 
<Referring Agency (if different to GP)>	
Position	<Referrer position (if different to GP)>	Email: <Referrer email (if different to GP)>
Phone: <Referrer Phone (if different to GP)>	
Reason for referral
(including mental health or drug and alcohol history / previous treatment, physical health, vocational/ educational)	<Reason for referral>	
Risk taking behaviours
(self-harm, suicide ideation, substance use, aggression, self-neglect)	<Risk taking behaviours>	
Involvement with other agencies / services (if yes, please provide details)	<Involvement with other agencies / services>	
Relevant medical details (please attach an existing GP Mental Health Treatment Plan if applicable)	<SelectedPMH>	

CONSENT TO REFERRAL
This referral has been discussed with the young person who has agreed to the referral to headspace and sharing of information related to referral

Young Person	

Signature: 	_____________________________ 	Date: ___ / ___ / ______

Print Name: 	_____________________________
	
Young Person's parent or caregiver (required if the young person is under 16 years of age)	

Signature: 	_____________________________ 	Date: ___ / ___ / ______

Print Name: 	_____________________________  Relationship: ___________________
	
Referrer	

Signature: 	_____________________________ 	Date: ___ / ___ / ______

Print Name: 	_____________________________

Office use only 
Confirmation sent by (name) __________________________ on (date) ___ / _____ / ______