headspace Malvern 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 Malvern 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 Malvern 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 receive this form, someone from the intake team will contact you to discuss your concerns.

Personal Details

First name: *

Surname (last name): *

Preferred name:

Gender: *

Date of birth: *

Pronouns:

Street address: *

Suburb: *

Contact number: *

Email: *

Young Person's Details

Please provide details about the person you are referring below:

First name: *

Surname (last name): *

Preferred name:

Gender: *

Date of birth: *

Pronouns:

Street address:

Suburb: *

Contact number: *

Email address:

What school does this student attend? *

Custody Arrangement / Legal Orders & Issues

Are any of the following in place or relevant to this referral? (tick all that apply) *

Please provide details (if known):

Carer/Legal Guardian details

If the young person is under 17yrs, please provide carer/legal guardian details below:

First name:

Surname (last name):

Phone number:

Email:

Relationship to the young person:

Is the parent/legal guardian aware of the referral (if under 17yrs)?

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

Custody Arrangements / Legal Orders & Issues

Are any of the following in place or relevant to this referral? (tick all that apply)

Please provide details (if known):

Referral Information

Presenting issues including any diagnosis: *

Reason for referral to headspace: *

Client history (relevant psychological, physical, social and family history): *

Other care providers involved (previous/current): *

Risk: *

Medications: *

*Please send through any relevant assessment and treatment documentation to:

Email: headspace.enquiries@accesshc.org.au | Fax: 03 9426 9591

Emergency Contact

First name: *

Surname (last name): *

Phone number: *

Email:

Relationship to you: *

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

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 we should know so you can safely access headspace Malvern?

Is there anything else you would like to add? *

About You

First name: *

Surname (last name): *

Contact number: *

Email: *

Where do you work? *

Where is your work located? *

What is your role?

What is your role? *

Your relationship to the young person: *

Why are you contacting us today? *

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.