headspace Hawthorn 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 Hawthorn and headspace Malvern are both run by the lead agency - Access Health & Community. Your referral may be viewed by the intake team for both sites. You will be asked which site you prefer to access. 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: *

What is your preferred centre? *

headspace Hawthorn 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 Hawthorn 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 the intake team will contact you to discuss your concerns.

What school does this student attend:

Is this a Victorian state secondary school? *

YesNo

The Victorian Department of Education and Training has engaged headspace to deliver counselling support to secondary students in Victorian Government 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

To refer a student under the EMHSS program, you will need to complete the EMHSS Consent Form in addition to this form.

Student details

Student first name: *

Student surname (last name): *

Preferred name:

Pronouns:

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

Gender: *

Phone number: *

Email address:

Street address:

Suburb: *

Personal Details

Your first name: *

Your surname (last name): *

Their first name: *

Their surname (last name): *

Preferred name:

Gender: *

Their preferred name:

Their gender: *

Date of birth: *

Pronouns:

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

Their pronouns:

Their street address:

Their suburb: *

Their contact number: *

Their email address:

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

YesNoUnsureN/A

Emergency Contact

Emergency Contact Details

If the client is under 18yrs, is their legal guardian aware of this referral?

Yes NoN/A

If the client is under 18yrs, is their legal guardian aware of this referral?

Yes NoN/A

Emergency contact name: *

Relationship to the young person: *

Emergency contact 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 18yrs, 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 Hawthorn?

About You

Your first name: *

Your surname (last name): *

Your relationship to the young person: *

Your contact number: *

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 Malvern & headspace Hawthorn contacting you. The intake team will make every effort to contact you within 2 business days.