Referral Form Please ensure all sections are completed and legible. This form can be to (02) 6024 5792, emailed to , or sent via post to 155 High Street, Wodonga VIC 3690. headspace Albury Wodonga is a voluntary service for young people aged 12-25 years of age. Headspace can only engage with the young person if they have consented to the referral. Has the person consented to the referral? YES NO ⎕ ⎕ Is the young person aged 12-25 years of age? YES NO ⎕ ⎕ headspace Albury Wodonga is not a crisis service; we are unable to support severe mental health issues or crisis referrals. Please call Mental Health Victoria 1300 881 104, NSW Access Line 1800 800 944, or in an emergency call 000 for immediate assistance. Details of Young Person If the young person is under 16 years of age, have the parents or carers of the young person consented to the referral? YES NO If no, why not? ⎕ ⎕ Surname: Name: Gender: Male Female Gender Diverse Intersex Indeterminate Other ⎕ ⎕ ⎕ ⎕ ⎕ ⎕ Date of Birth: Address: Suburb: Postcode: Phone (home): Phone (mobile): Email: Preferred method of communication? Phone (home) Phone (mobile) Email ⎕ ⎕ ⎕ SMS ⎕ Do you identify as: Aboriginal Torres Strait Islander Nationality: ⎕ ⎕ Preferred language: Interpreter required: YES NO ⎕ Emergency Contact: Name: Relationship to young person: Address: Suburb: Postcode: Phone (home): Phone (mobile):
Referral Form Please ensure all sections are completed and legible. This form can be to (02) 6024 5792, emailed to , or sent via post to 155 High Street, Wodonga VIC 3690. headspace Albury Wodonga is a voluntary service for young people aged 12-25 years of age. Headspace can only engage with the young person if they have consented to the referral. Has the person consented to the referral? YES ⎕ NO ⎕ Is the young person aged 12-25 years of age? YES ⎕ NO ⎕ headspace Albury Wodonga is not a crisis service; we are unable to support severe mental health issues or crisis referrals. Please call Mental Health Victoria 1300 881 104, NSW Access Line 1800 800 944, or in an emergency call 000 for immediate assistance. Details of Young Person If the young person is under 16 years of age, have the parents or carers of the young person consented to the referral? YES ⎕ NO ⎕ If no, why not? Surname: Name: Gender: Male ⎕ Female ⎕ Gender Diverse ⎕ Intersex ⎕ Indeterminate ⎕ Other ⎕ Date of Birth: Address: Suburb: Postcode: Phone (home): Phone (mobile): Email: Preferred method of communication? Phone (home) ⎕ Phone (mobile) ⎕ Email ⎕ SMS ⎕ Do you identify as: Aboriginal ⎕ Torres Strait Islander ⎕ Nationality: Preferred language: Interpreter required: YES ⎕ NO Emergency Contact: Name: Relationship to young person: Address: Suburb: Postcode: Phone (home): Phone (mobile):