Headspace Adelaide Referral Form

headspace Adelaide

Community Referral Form

GPs to complete Mental Health Treatment Plan

(MHTP not required for the Youth Early Psychosis Program)

Please fax referral to headspace Adelaide on 1800 632 193

Date of Referral:

Name: / D.O.B.: / Gender:
Address:
/ Phone: / Email:

Young Person Details

If under 16, is the parent or caregiver aware of the referral? Yes ☐ No ☐
Cultural background: Aboriginal ☐ Torres Strait Islander ☐ Culturally and Linguistically Diverse ☐
Best method of contact: SMS ☐ Email ☐ Letter ☐ Mobile ☐

Emergency Contact

Name: / Phone:
Relationship to Young Person:

Referrer Details

Name: / Contact Number:
Organisation: / Contact Fax Number:
Email Address: / Relationship to Young Person:

GP Details

Name: / Phone: Fax:
Practice: / Address:

(please circle)

Are any other services involved in supporting this young person? Yes No
Name: Phone:
Organisation:

Reason for Referral Please provide us with some information about the main reason for referring this young person including note of any current risk issues.Please note: If the young person being referred needs an immediate service/assistance please contact Emergency Mental Health Services on 8161 7000 (under 16) or 13 14 65 (over 16).

Risk:
Risk of harm to:  Self  Others  Both  Other  NA
ALERTS: NA
None  / Low  / Moderate  / Significant  / Extreme 
No thoughts or action of harm / Fleeting thoughts of harming themselves or harming others but no plans, current low alcohol or drug use. / Current thoughts/distress, past actions without intent or plans, moderate alcohol or drug use / Current thoughts/past impulsive actions/recent impulsivity/some plans, but not well developed. Increased alcohol or drug use. / Current thoughts with expressed intentions/past history/plans. Unstable mental illness. High alcohol or drug use, intoxicated, violent to self/others, means at hand for harm to self/others
Comments:
Preference of Clinician: Male  Female  Either
Request for Collateral documentation Yes No Not available
Plan:

Young Person and Carer Consent for Referral and Information

I (young person) , being 16 years or older, agree to be referred to headspace Adelaide and give my permission for (referrer’s name) to exchange information with headspace Adelaide for the purpose of this referral.
I (carer) agree for (young person) to be referred to headspace Adelaide and for information to be shared as above.

Young person signature ……………………………………………………….. Date .……………………………

Referrer/Carer signature ………………………………………………………. Date …………………………….

Office Use Only

Appointment Booked (please circle): headspace clinician private clinician GP MATT UHR CCT

Date and time of booked appointment:

Referred elsewhere (details):

Person completing this form:

Date Time: