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	<<Patient Demographics:First Name>> <<Patient Demographics:Surname>>	Date of Referral 
<<Miscellaneous:Date>>	
Gender	<<Patient Demographics:Gender>>	D.O.B. 
<<Patient Demographics:DOB>>	
Is the young person of Aboriginal and or Torres Strait Islander descent?
<<Of Aboriginal and/or Torres Strait Islander descent?>>	
Address	Street: <<Patient Demographics:Address Preferred>>
Suburb: <<Patient Demographics:Address Preferred City>>   Postcode: <<Patient Demographics:Address Preferred Postcode>> 	
Contact Details	Mobile: <<Patient Demographics:Phone (Mobile)>>  Home: <<Patient Demographics:Phone (Home)>>
Email: <<Patient Demographics:E-mail>>	
Preferred contact	<<Preferred method of contact>>	
Next of Kin/Emergency contact name	<<Next of Kind/Emergency Contact name>>	Relationship: <<NOK/Emergency Contact relationship>>
Phone: <<NOK/Emergency Contact Phone>>	
GP name	<<Doctor:Name>>	Practice Name:<<Practice:Name>>
	
GP contact details	Phone: <<Doctor:Phone>>	Email: <<Doctor:E-mail>>	
Can we contact the GP? <<Can we contact GP?>>	

Referrer name
(if different to the GP)	<<Referrer name (if not GP)>>	Referring Agency 
<<Referring Agency (if not GP)>>	
Position	<<Referr Position (if not GP)>>	Email: <<Referrer email (if not GP)>>
Phone: <<Referrer Phone (if not 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)	<<Relevant medical details>>	

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) ___ / _____ / ______