REFERRAL FORM: Please fax or email referral form to headspace Inala Team –

07 3279 8444 or

Young Person Details

Name:
Date of Birth: / Gender: / Aboriginal: Yes/No
Torres Strait Islander: Yes/No / Nationality:
Interpreter required: Yes/No
Language if yes:______
Address:
Suburb: Post code:
Home Phone: / Mobile: / Other Contact:
School/Other Education Facility Attending:
Do you have Case Worker? :
Are you Registered with an Employment Facility:
Referral Date:
Referred By:
Organization/School: / Position:
Contact No: / Mobile:
Email: / Fax:
Self-Referral from young person: Yes No - If yes, skip the next question
Young Person Consent: Yes No
Carer aware of referral: Yes No
Carer name/s: ______Contact details:______
Is there an existing Mental Health Care Plan?: Yes No
If no, it may be beneficial to suggest that the young person/support person consider getting a MHCP from their General Practitioner so that they can be booked with a psychologist more quickly after initial assessment at headspace Inala.
If yes: GP Name:
Medical Practice:
Date created:

Presenting issues/concerns:

Diagnosis/Issues
Anxiety
Depression
Schizophrenia/Schizoaffective disorder
Bipolar Affective Disorder
Personality disorder
PTSD/trauma history
Eating problems/disorder
Asperger’s/Autism
ADHD/ADD
Physical disability
Intellectual disability
Drug or alcohol use/problem
Anger management issues
Grief and Loss
Sexual identity concerns
Gender identity concerns
Physical health concerns
Sexual health concerns
Legal issues
Youth Justice/Probation and Parole client
Past or present contact with DOCS
Pending legal matters
Risk
Self-harming behaviours
Thoughts of suicide
Threats to others (verbal)
Harm to others (aggressive)
Presentation to ED or hospital
History of hospitalisation
History of suicidal behaviour
Criminal activity/police involvement / Social Issues
Financial difficulty
Family problems
Social problems
School expulsions/suspensions
Domestic violence
Sexual abuse
Physical abuse
Relationship concerns
Bullying/cyber bullying/harassment
Behaviours/concerns
Withdrawn/isolated
Crying
Difficulty sleeping/sleeping too much
Refusing school
Low self esteem
Body image problems
Not themselves/personality change
Snappy/irritable/grumpy
Stressed/worried more than usual
Lack of motivation/not interested
School grades/behaviour declining
Additional notes:






REFERRAL FORM: Please fax or email referral form to headspace Inala Team –

07 3279 8444 or

Once received:

If the young person has given consent, headspace Inala will contact the young person using the details provided and book an appointment.

Your feedback on our website and referral process is valued. Feedback can be faxed or emailed as above.

Thank you for your referral

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