Please sign and submit the completed form to info@headspacejoondalup.com.au or fax to 9301 0859 Referrals will not be accepted without the signed consent of the young person (see overleaf)

Name of young person 	Patient Demographics.Full Name
	Date of Referral Date of Referral	
Gender	 Male      Female      Other	D.O.B Patient Demographics.DOB
	
Is the young person of Aboriginal and or Torres Strait Islander descent? (tick as appropriate)

false No      Yes, Aboriginal      Yes, Torres Strait Islander      Yes, Aboriginal & Torres Strait Islander	

Address	Street name: Patient Demographics.Address
Suburb: Patient Demographics.Suburb Postcode: Patient Demographics.Postcode

Contact details	Mobile: Patient Demographics.Phone (Mobile) Home Phone: Patient Demographics.Phone (Home) 
Email: Patient Demographics.E-mail

Preferred contact	
false Mobile      Home Phone      Email      Post	
Next of Kin/Emergency contact name	Patient Demographics.NOK Name	Relationship Patient Demographics.NOK Relationship
Phone Patient Demographics.NOK Mobile Phone	
GP name
	Treating Doctor.Name	Practice Name Practice Name	
GP contact details
	Phone: Practice.Phone	Email: Addressee.E-mail	

Can we contact the GP?  Yes      No      Unsure	

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

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) ___ / _____ / ______