headspace Professional Referral STOP - Referring yourself or a friend/family member? Please use the Self Referral Form.This form is designed for you to refer a client/patient to headspace Launceston or headspace Devonport.Please note: headspace Launceston and headspace Devonport are not acute mental health services or crisis services. If you have concerns for a person's immediate safety please contact the Mental Health Helpline on 1800 332 388. For urgent medical assistance please call: 000.Privacy is important to us. This info will be kept confidential and used only to provide the best care possible. Please read the headspace 'Just between us' confidentiality statement.Has your client/patient read and agreed with the headspace 'Just between us' confidentiality statement? (Link Above)*YesIs this referral to headspace Launceston, headspace Devonport or headspace Burnie?*LauncestonDevonportBurnieYoung Person DetailsFirst Name:*Last Name:*Gender:*Date of birth:*Street Address:*Town/Suburb:*Postcode:*Home Phone: Mobile Phone:*Email:Which contact(s) would you prefer us to use? (you can select more than one)*EmailMobile PhoneHome PhoneVoicemailLetterWho should we contact to make an appointment? *Young PersonReferrerFamily MemberIs the young person Aboriginal/Torres Strait Islander? *YesNoBothDo they require an Interpreter? *YesNoPreferred Language:*Does the young person have a current Mental Health Care Plan?*YesNoIs the young person aware of this referral? *YesNo We are unable to make contact with them if the answer is NO.Referrer DetailsYour Name:*Your Organisation:*Your Role:*Do you require a copy of this referral for your records?*YesNoYour Email:*Will you or another organisation have continued contact with the young person? *YesNoOther Supports/OrganisationsIs there a family member or worker you would like us to speak to? *YesNoTheir Name:*Their Phone:*Their Relationship to young person:*If under 16 are the young person's parents/carers aware of this referral? *YesNoOver 16Is the young person working with any other organisations? *YesNoDetails*Does the young person have an NDIS Plan? *YesNoEmergency Contact/Next of kin - MUST BE OVER 18Name:*Relationship to young person:*Phone:*Medicare/Centrelink:Do you know the young persons Medicare Details? *YesNoMedicare Card Number*Line Number*Medicare Expiry Date:*Does the young person have a regular Doctor?*YesNoDoctor's Name:*Medical Practice:*Does the young person have a Health Care Card or Pension Card?*YesNoCentrelink Reference Number: (if known)Expiry Date: (if known)Reason For ReferralPlease list the main reasons for referral:*Please attach any relevant assessments/informationAre there any general health issues limiting the young persons day to day or social activities?*YesNoAre drugs and/or alcohol having a negative impact on areas of the young person's health or lifestyle? *YesNoDoes the young person require support with education, training and/or employment?*YesNoSubmitReset
