Reason/s for Referral Wellbeing and Mental Health General or Sexual Health Alcohol and other Drugs ⎕ ⎕ Work, School, Study Please specify: ⎕Other Main issue/s: Relevant past history: Does the person currently see any other services: YES NO ⎕ ⎕ If yes, please tick appropriate box/boxes: Drug and Alcohol School/Other Counsellor ⎕ ⎕ Youth Justice/Juvenile Justice(VIC & NSW) Community Services Adult Mental Health ⎕ ⎕ ⎕ CAMHS/NECAMHS Child Protection ⎕ ⎕ Other Service: ⎕ Does the young person have a regular GP? YES NO If yes, please provide details ⎕ ⎕ below: Name of GP: Contact Details: Name of Service Provider: Phone: Is the other service aware of the referral to headspace? YES NO ⎕ ⎕ Will the services involved continue working with the young person? YES NO ⎕ ⎕ What are your expectations of headspace Albury Wodonga? Details of Referrer Name of referrer: Organisation: Relationship to young person: Address: Suburb: Postcode: Phone (business hours): Phone (mobile): Email:
Reason/s for Referral Wellbeing and Mental Health ⎕ General or Sexual Health ⎕ Alcohol and other Drugs Work, School, Study ⎕Other Please specify: Main issue/s: Relevant past history: Does the person currently see any other services: YES ⎕ NO ⎕ If yes, please tick appropriate box/boxes: Drug and Alcohol ⎕ School/Other Counsellor ⎕ Youth Justice/Juvenile Justice(VIC & NSW) ⎕ Community Services ⎕ Adult Mental Health ⎕ CAMHS/NECAMHS ⎕ Child Protection ⎕ Other ⎕ Service: Does the young person have a regular GP? YES ⎕ NO ⎕ If yes, please provide details below: Name of GP: Contact Details: Name of Service Provider: Phone: Is the other service aware of the referral to headspace? YES ⎕ NO ⎕ Will the services involved continue working with the young person? YES ⎕ NO ⎕ What are your expectations of headspace Albury Wodonga? Details of Referrer Name of referrer: Organisation: Relationship to young person: Address: Suburb: Postcode: Phone (business hours): Phone (mobile): Email:
Referral-Guidelines-and-Form-2017-V3.docx