Date of Is client aware of Yes No Referral: referral? Self Doctor: _________________________ Walk in Referral School Friend/Family Member Referral Type: Source: Email Fax Service Provider: __________________________ Client Details Name: Date of Birth: Address: Place of Birth: Male Gender Diverse Unsure Suburb: Gender: Female Mobile: Ethnicity: Health Care No: Expiry: Card Medicare No: Reference: Expiry: Do you suffer from any of the following health conditions? Diabetes Heart Disease Epilepsy Lung Disease Allergies: ______________________ Kidney Disease Arthritis Asthma Low/high Blood Pressure ________________________________________________________________________________ Emergency Contact Details Name: Phone: Address: Email: Can we contact this person about your Relationship: Yes No appointments? Referrer’s Details Referrer’s Details: Same details as Emergency Contact Name: Relationship: Address: Organisation: Email: Can we contact this person about your appointments? Yes No Reason/s for Referral: Mental Health Drugs and Alcohol School/Work General Health Example : feeling stressed and anxious. What has prompted you to make contact with headspace? PLEASE COMPLETE BOTH SIDES OF THIS FORM
Date of Referral: Is client aware of referral? Yes No Referral Type: Walk in Email Fax Referral Source: Self Doctor: _________________________ School Friend/Family Member Service Provider: __________________________ Client Details Name: Date of Birth: Address: Place of Birth: Suburb: Gender: Male Gender Diverse Unsure Female Mobile: Ethnicity: Health Care Card No: Expiry: Medicare No: Reference: Expiry: Do you suffer from any of the following health conditions? Diabetes Heart Disease Epilepsy Lung Disease Allergies: ______________________ Kidney Disease Arthritis Asthma Low/high Blood Pressure ________________________________________________________________________________ Emergency Contact Details Name: Phone: Address: Email: Relationship: Can we contact this person about your appointments? Yes No Referrer’s Details Referrer’s Details: Same details as Emergency Contact Name: Relationship: Address: Organisation: Email: Can we contact this person about your appointments? Yes No Reason/s for Referral: Mental Health Drugs and Alcohol School/Work General Health What has prompted you to make contact with headspace? Example : feeling stressed and anxious. PLEASE COMPLETE BOTH SIDES OF THIS FORM
Referral-Consent-Confidentiality-2017.docx