headspace South Melbourne Online Referral Form

Welcome to headspace South Melbourne!

Whether you're looking for support for yourself or for a young person in your life, we're glad you've reached out! Completing this form is the first step in connecting with our team.

Important information

headspace is not a crisis service. If you or someone else is in immediate danger or needs urgent support, call 000 immediately.

headspace South Melbourne is operated by Access Health & Community. To help connect young people with the right support as quickly as possible, information from this referral may also be reviewed by the intake teams at headspace Hawthorn and headspace Malvern.

Your privacy is important to us. Information provided through this form is stored securely and handled confidentially.

Before continuing, please take a moment to read our:

Finding the right headspace centre

headspace South Melbourne is located at 329 Dorcas Street, South Melbourne, if you are looking for a location closer to where to where you live, please click here.

Acknowledgement of Country

headspace South Melbourne acknowledges the Traditional Custodians of these beautiful lands, on which we work, and pays respect to Elders past and present.

We welcome and celebrate people of all cultures, identities, backgrounds, abilities, genders and sexualities, and are committed to providing a safe, inclusive and respectful service for everyone.

I have read and understood the information above.
*

Today's date *

Who are you completing this form for? *

MyselfSomeone else

headspace South Melbourne is a voluntary service. It's important the person you are referring agrees for you to provide their details and is willing to access the service. Do you have consent to provide their personal details? *

YesNo

Tell us about yourself!

First name *

Surname *

Preferred name

Pronouns *

Date of birth *

Gender *

Email *

Phone number *

Street address *

Suburb *

Do you identify as Aboriginal or Torres Strait Islander? *

Do you prefer speaking a language other than English? *

YesNo

If yes, what is your preferred language?

Would you like an interpreter? Tick this box if yes.

Do you have any accessibility needs?

Is there anything we can do to make it easier to access support at headspace South Melbourne?

Details of the young person seeking support

First name *

Surname *

Preferred name

Pronouns *

Date of birth *

Gender *

Email *

Phone number *

Street address *

Suburb *

Does the young person identify as Aboriginal or Torres Strait Islander? *

Does the young person feel more comfortable communicating in a language other than English? *

YesNo

If yes, what language does the young person feel most comfortable communicating in?

If the young person is under 18, are there any parenting arrangements, guardianship arrangements, or court orders that it would be helpful for us to know about? *

YesNoUnsurePrefer not to say

If yes, please tell us a little more *

Details of the person making this referral

First name *

Surname *

Email *

Phone number *

What's your relationship to the young person? *

What would you like us to know about the young person and the support they are seeking?Please tell us a bit about what has led to this referral, your relationship to the young person, and any other information you think would be helpful for us to know.

Emergency contact details

First name *

Surname *

Phone number *

Email *

What's this person's relationship to you? *

Relationship to the young person: *

What support are you looking for at the moment?

Select all that apply.

Is there anything else you would like us to know about what's been going on?

One last question!

Once you submit this form, you consent to headspace South Melbourne contacting you.

You can expect our team to contact you within 5-7 business days, once we receive your referral.

headspace South Melbourne opening hours:

Monday-Thursday: 9.30am - 6.00pm | Friday: 8.30am - 5.00pm | Weekends & Public Holidays: Closed

You’re welcome to bring a support person with you to your appointments if it helps you feel more comfortable. This could be a parent or carer, family member, friend, support worker or another trusted person.