Physical & Sexual Health Referral Form

Thank you for completing this form.

Before you proceed, if you are concerned for your or someone else's safety, please contact 000 immediately.

All information is private and confidential, and is stored on a secure server.

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

Given Name (first name) *

Surname (last name) *

Preferred Name

Date of Birth *

Title

Gender *

Pronouns

Occupation *

Contact Information

Moblie *

Home Phone

Email Address

Work Phone

Can we leave a message? *

Yes No

Can we send you a SMS reminder? *

YesNo

Home Address:

Suburb

Postcode *

Is your postal address different to your residential address? *

Yes No

Postal Address:

Postcode:

Suburb:

Emergency Contact Details

Emergency Contact

Emergency contact number

Emergency contact relationship to you

Is your next of kin the same as your emergency contact?

YesNo

Next of Kin Contact:

Next of Kin Contact Number:

Next of Kin Relationship:

Additional Information

Country of Birth

Cultural Background

Preferred Language

Do you need an interpreter? *

YesNo

If yes, which language? *

Are you Aboriginal or Torres Strait Islander? *

No Aboriginal Torres Strait IslanderAboriginal and Torres Strait IslanderPrefer not to say

Do you have a carer?

I have a carer who lives with meI have a carer who doesn't live with me I don't have a carer but I need one I do not need a carer

Do you have any accessibility needs?

Physical Health

In a few words, what support are you seeking from our Youth Health Nurse? *

Lifestyle

Smoking

Non smokerEx smokerSmoker

Current Alcohol

Non drinkerDrinker

Medical History

Medications (including injections, vitamins and supplements)

Allergies and reactions

Pre-existing medical conditions or surgeries

I understand that my information may be shared with other staff at AccessHC or to other health professionals to allow quality medical care *

I consent for my appointments to be bulk billed under Medicare *

I have received a copy of the brochure 'Rights and Responsibilities' *

Signature: *

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Date *

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.

Please call us on 03 88504180 if needed.

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