Welcome

Welcome to the headspace Narooma Referral Form.

We are not a crisis service. If you are in crisis, call the Mental Health Line on 1800 011 511 OR Lifeline on 13 11 14. If you are in immediate danger, please call 000.

You can complete this form yourself or call the centre so we can assist you in completing it over the phone.

Free call 1800 343 999 or (02) 4476 4176.

After this form is submited, a member of our team will be in touch with you.

What is your preferred headspace Location? *

headspace Naroomaheadspace Moruya

I would like to refer: *

MyselfMy Friend / My ChildStudent / Client / Patient

If you are referring a young person, have they consented to this referral? *

YesNo

Thank you for letting us know.

headspace Narooma is a voluntary service for young people aged 12-25 years of age. We can only engage with young people if they have consented to the referral and are old enough to consent.

Please contact the Centre on Free call 1800 343 999 or (02) 4476 4176.

Which Services are you interested in? *

Alcohol & Other DrugsMental Health & WellbeingSexual HealthWork & Study

Is there anything you would like us to note, so we can better support you? *

Privacy & Confidentiality

headspace Narooma has a Privacy policy which covers the collection, storage, disclosure and security of patient information. The Policy conforms with the Privacy Act and Health Records Act and all other relevant Government laws and regulations.

The information gathered by any headspace Narooma staff member is kept on your secure electronic file, which can be accessed only by staff who are assisting with your care.

The information that you provide us, remains confidential and secure, except where:

The information you provide us indicates that you, or another person, may be at imminent risk; or
Information is subpoenaed by court; or
Your prior consent has been obtained to provide verbal or written information to a person or an organisation.

If at any time it is considered that you may be at imminent risk of hurting yourself, or others, it is our duty of care to ensure the wellbeing of all, and we may be required to involve other people or organisations.

You also hold the right to request access to the information collected about me and request amendment if l believe it to be inaccurate. I understand that in some circumstances access might be legitimately withheld, however, l will be given an explanation in these circumstances.

headspace Narooma form part of your Care Team, and therefore should you choose to access FPS sessions/counselling services we work with your referring GP by providing them with progress reports throughout your treatment

Collection and Use of Personal Information

Please tick this box to ensure you understand the information above *

Young Person

Legal First Name *

Legal Last Name *

Preferred Name

How do you describe your gender?

Pronouns

Date of Birth *

Mobile *

Phone

Email *

How would you prefer us to contact you for Appointments?

Phone or text me directlyPhone my Parents / Carer

Preferred contact Person & Phone Number / Email (for appointments only)

Residential Address *

Street address *

Suburb *

State *

Postcode *

Are you a refugee or from a migrant family/community?

YesNoUnsure

Country:

Do you require an interpreter during your intake or consultations? *

YesNo

If you require an interpreter, what language/s, including Australian Sign Language (ASL) is required? *

Is there anything we can do to make accessing the service easier for you?

Referrer

Referrers’ Name / Organisation *

Relationship to young person: *

Referrer’s Phone number: *

Referrer’s Email Address: *

Risk

In the past two weeks, have you thought about ending your life? *

YesNo

In the past two weeks, have you deliberately harmed yourself /had thoughts of harming yourself? *

YesNo

Have you ever tried to end your life? *

YesNo

If yes, and you're comfortable sharing, please provide any additional details: when and how it happened, what occurred, and what was happening in your life at that time:

Current Services

Current Service Information

Do you have an existing General Practice/Doctor? *

YesNoUnsure

Details: *

Are any other services supporting you or your family at the moment? *

YesNoUnsure

Details: *

Do you have an existing Mental Health Treatment Plan? *

YesNoUnsure

Do you have an existing counsellor? *

YesNoUnsure

Details: *

Have you accessed counselling sessions services this calendar year? *

YesNo

How many? *

Do you have any current Court Orders (AVO, DVO, parole/probation)? *

YesNoUnsure

Details: *

Do you have a NDIS plan? *

YesNo

Does it include Psychology?

YesNo

Please Note: The young person will not be eligible to receive psychology / mental health services at headspace Narooma but may be eligible for other headspace Narooma

Once you submit this form, you consent to headspace Narooma contacting you on the details provided.  

A confirmation email will be sent to you acknowledging the referral.

We will make every effort to contact you within 3 business days. 

headspace Narooma is not a crisis service if you are experiencing a mental health crisis please contact emergency services via 000 or one of the below acute mental health services: 

Mental Health line: 1800 011 511

Lifeline (24/7): 13 11 14 or webchat/text at  lifeline.org.au