headspace South Melbourne Online Referral Form

Thank you for referring to headspace.

We are not a crisis service. If you are concerned for your or someone else's safety, please contact 000 immediately.

headspace South Melbourne is run by the lead agency - Access Health & Community . Your referral may be viewed by the intake teams at other headspace Centres Hawthorn & Malvern. All your information is private and confidential and all information you submit on this form, is stored on a secure server.

Please ensure you read 'Your Rights and Responsibilities' document and the Privacy Statement before proceeding with this form.

Please tick this box to ensure you understand the information above *

Today's date *

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

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

Thank you for letting us know.

Please fill in your personal details below. Once we recieve this form, someone from our team will contact you to discuss your concerns.

What school does this student attend: *

Is this a Victorian state school?

YesNo

The Victorian Department of Education and Training has engaged headspace to deliver counselling support to students in Victorian Government Seconday Schools. The counselling support is designed to increase the availability of mental health support for students, improve mental health outcomes for students and assist students in finding the right support as appropriate. This program is called EMHSS (Enhancing Mental Health Support in Schools).

Would you like to refer this student under the EMHSS program? *

YesNo

EMHSS Consent Form

To refer a student under the EMHSS program, please continue with this form.

Aleternatively, you can send a copy of the completed EMHSS Consent Form to our reception team.

I confirm all of the information contained in the EMHSS Consent Form has been read to the student/parent/carer and a clear and thorough record of the conversation and consent is documented by the Health and Wellbeing Key Contact. *

I confirm the student has consented to this referral. *

I confirm I have assessed whether the student's parent/guardian needs to consent to this referral, and have obtained consent where required (e.g. if the student is under 18, or not a mature minor). *

Student details

Student first name: *

Student surname (last name) *

Student preferred name:

Student pronouns

Student D.O.B *If you don't know the young person's D.O.B, please provide their age

Student Gender: *

Student phone number: *

Student email address

Student street address:

Student suburb *

Parent/Carer Details

If the student is under 18, or not a mature minor, please provide parent/carer details below:

Parent/carer name:

Relationship to client:

Parent/carer phone number:

Parent/carer email:

If under 18 years of age, is there any shared care arrangement or court orders with parents?

YesNoUnsureN/A

If yes, please provide additional information? *

Personal Details

Your first name: *

Your surname (last name): *

Their first name: *

Their surname (last name): *

Preferred name:

Pronouns

Their preferred name:

Their Gender: *

Date of birth: *

Gender: *

Their date of birth: *If you don't know the exact date, please provide their age

Their contact number: *

Their email:

Their Suburb *

Street address: *

Suburb *

Contact number: *

Email: *

If under 18 years of age, is there any shared care arrangement or court orders with parents? *

YesNoUnsureN/A

If yes, please provide further information

If under 18 years of age, is there any shared care arrangement or court orders with parents? *

YesNoUnsureN/A

Emergency Contact

Emergency Contact Details

Emergency contact name: *

Relationship to the young person: *

Emergency contacts name: *

Relationship to you *

Phone number *

Email

If we are required to contact this person, is there anything we should be aware of?

Why are you contacting us today?

Is there anything else you would like us to know?

Additional Information

If under 18 years of age, is there any shared care arrangement or court orders with parents? *

Are you Aboriginal or Torres Strait Islander? *

Do you need an interpreter? *

Do you have any accessibility needs?

Is there anything else we should know so you can safely access headspace South Melbourne?

About You

Your first name: *

Your surname (last name) *

Your relationship to the young person: *

Your contact number: *

What school does this student attend:

Why are you contacting us today? *

Please provide a brief description of why you are referring this student to headspace: *

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

You can expect our team to contact you within 5 business days.