Referral Form

Important information regarding your referral, please read:

If the young person is experiencing high levels of distress which may result in harm to themselves or others, or is at high or acute risk of suicide, they are not suitable for headspace services. Please contact 1300 642 255 (24 hours) to speak to an Acute Care Clinician, refer them directly to the Emergency Department of the nearest hospital, or contact emergency services on 000.
headspace is an early intervention and prevention service. We offer short-term brief intervention to young people between the ages of 12 to 25 who are experiencing mild to moderate mental health issues.
After we have received this referral, you will be contacted within 5 business days to arrange an initial triage appointment.
This triage appointment will be arranged within 3 weeks of initial contact.
Please note we are a voluntary service, and we can only engage with young people who have provided consent to the referral.
Please note that receipt of the referral does not indicate acceptance to headspace services. We may complete a needs assessment with the young person to determine their most suitable care options. headspace may support the young person by referring them to other services when deemed appropriate.
Our centre collaborates with other Wesley Mission Queensland headspace centres. Those centres may have additional capacity to support our young people via telehealth or video appointments where applicable.
Please provide and attach as much information as possible as it ensures the best quality of care.This may include things like - discharge notes, safety plans, risk assessments.
Request of referral will be provided directly to the referrer via email, phone or fax. If no contact is made please call the centre on 07 4303 2100.

Referrer name *

Referrer address

Street address

City

State

Postcode

Referrer email address

Referrer phone

Referral date

Name of service provider

What school does the young person attend? (If applicable)

Is the young person aware of this referral and willing to engage in services?

YesNo

Client Details

First Name(s) *(as it appears on your Medicare Card)

Last Name *(as it appears on your Medicare Card)

Preferred Name

Date of Birth *

Identified Gender

If "other" gender, please specify

Sexual Orientation

"Other" sexual orientation

Pronouns

Pronouns (other)

Client Identity

Ethnicity

Young person’s phone number *

Would you like this number to be used as our main contact?

YesNo

Does the young person give us permission to send SMS’s

YesNo

Email

Residential address *

City *

State *

Postcode *

Do you consent to headspace sending correspondence to this address?

YesNo

If no, please provide an alternative postal address

Postal address

City

State

Postcode

External Service Involvement (i.e. Child Safety, Youth Justice, etc)

Service Name:

Contact Person:

Service Name:

Contact Person:

Is the young person linked in with child safety

YesNo

Child Safety Contact:

Parent, carer or guardian details (for young people, 15 years and under)

Name

Relationship to young person

Parent, carer or guardian email

Parent, carer or guardian phone

Street address

City

State

Postcode

Emergency Contact / Next of Kin: In case of an emergency, who should we contact?

Name

Relationship to young person

Mobile Number

Street address

City

State

Postcode

Reason for Referral

Reason for referral and any additional information (Please write a brief summary for the reason of this referral and any additional information that may assist) *

Consent and Signature

Consent to share

Headspace Fraser Coast is funded through the Country to Coast Primary Health Network (CCQ). The CCQ has a key role in working with a range of primary health care services, health professionals, service providers and the community to enhance the efficiency and effectiveness of services in the area. I consent for my information to be shared with: Country to Coast Primary Health Network De-identified data may be provided to the Australian Department of Health, Disability and Ageing and headspace national for statistical and evaluation processes.

By signing below, I hereby acknowledge that I have read and understand the above.

PRIVACY STATEMENT: Any personal information is collected, used and disclosed by Wesley Mission Queensland in accordance with our Privacy Policy available at www.wmq.org.au/privacy-policy

By signing below, I hereby acknowledge that I have read and understand the above.

Signature *

Draw signature|Type signatureClear

Date *

Parent/Guardian/Carer Name Signature

Draw signature|Type signatureClear

Parent/Guardian/Carer Name(if young person is under the age of 15)

The parties agree to use electronic signatures for signing documents. Electronic signatures shall have the same legal effect as handwritten signatures under the Electronic Transactions (Queensland) Act 2001.