Family, Friends and Professionals Referral

You can get support for your mental health by creating a headspace account at headspace.org.au, or you can speak to someone 1-on-1 via online chat, email or over the phone at eheadspace.org.au or 1800 650 890

If you are in immediate risk, please contact Bendigo Psychiatric Triage on 1300 363 788, this number is contactable 24 hours a day, 7 days a week or call 000.

If you need to speak to someone urgently:

Lifeline 13 11 14

Kids Helpline 1800 551 800

Suicide Call Back Service 1300 659 467

Please note: We are currently NOT accepting referrals for ADHD assessments

Your details

Name of person submitting this referral *

Relationship to young person *

Email address of referrer *

Contact number of referrer *

Is the young person between the ages of 12 and 25? *

YesNo

Is the young person aware of and have they consented to this referral? *

YesNo

Has the young person seen anybody at headspace Bendigo before? *

YesNo

Does the young person have a current Mental Health Care Plan? *

YesNo

If the young person is in school, which school do they attend? *

Young person's details

First name *

Last name *

Affirmed name

Date of birth *

What does the young person identify as? *

MaleFemaleNon binaryOther

Please specify

Does the young person identify as Aboriginal or Torres Strait Islander? *

Allergies (if known) *

Address *

Phone number *

Email *

Medicare card number

IRN

Medicare Expiry Date

Do they have a Healthcare or Concession / Pension card? *

YesNo

Health Care Card or Pension Card number *

Expiry? *

Is it okay for us to contact the young person directly to make an appointment? *

YesNo

Country of birth/ethnicity

Preferred language

Does the young person need an interpreter? *

YesNo

Is there a family member or support person the young person would like us to speak to? *

YesNo

Name of family member/support person

Phone number

Were there any other services previously involved? *Youth Mental Health Team, CAMHS, Bendigo Mental Health Team, CASA, Anglicare, Haven, Youth Justice ect.

Are there any other services currently involved? *Youth Mental Health Team, CAMHS, Bendigo Mental Health Team, CASA, Anglicare, Haven, Youth Justice ect.

Emergency contact

First name *

Last name *

Relationship to young person *

Phone number *

What is your reason for referring the young person to headspace Bendigo?

Please specify

Please tick box if you/young person DO NOT want a call to talk about other programs offered at headspace Bendigo

Tell us more here

Reason for referral *

Young persons goals *

Upload any relevant supporting documents - Shared support plan, relevant assessments, mental health care plan ect.

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Your privacy is important to us. This information will be kept confidential and used only to give you the best care possible.

https://www.bchs.com.au/about/policies/privacy-policy

I have read and understand this privacy information

YesNo