Please fax referral to 02 8048 3399 or email to headspace.hurstville@cesphn.com.au
Please ensure all sections are completed, UPPERCASE and legible.	
Our Intake Officers may be contacted during business hours on 02 8048 3350.	
Please note that we are NOT A CRISIS SERVICE. If crisis assistance is required, please call the NSW Mental Health Triage on 1800 011 511. Alternatively, direct your YP to an accident & emergency department of their nearest hospital.	
Has the Young Person (YP) consented to referral?  	Yes		If "NO" referral cannot be accepted	
If the YP is under 16 years & living with parents/carers,  are they aware?	Yes		No		N/A		

YOUNG PERSON'S DETAILS:	
First Name: 	<PtFirstName>	Surname:	<PtSurname>	
Preferred Name:		
DOB: 	<PtDoB>	Age: 	<PtAge>	Gender: 	<PtSex>	
Street Address:  	 <PtStreet>	
Suburb: 	<PtCity>	Post Code: 	<PtPostcode>	
Home Phone:	<PtPhoneH>	Can We Leave a Msg: 	<Okay if voicemail is left on home phone?>	
Mobile: 	<PtPhoneMob>	Can We Leave a Msg: 	<Okay if voicemail is left on mobile?>	
Email: 	<PtEmail>	
Can we post letters to the above address?	<Can letters be posted to address in this referral?>	

[MANDATORY FIELD] NEXT OF KIN (NOK) DETAILS: must be responsible adult >18yo.	
Name: 	<NOK (next of kin) Name: >	
Relationship:	<Relationship of NOK to young person>	
Street Address: 	As Above			
Suburb: 		Post Code: 		
Phone: 	<NOK phone>	Mobile: 	<NOK Mobile>	
Can we contact NOK?                             Yes		                                                Emergency Only		

REFERRER’S DETAILS:	
Name of referrer: 	<DrName>	
Relationship to YP:	General Practitioner	
Organisation Name: 	<Practice>	
Street Address: 	 <DrStreet>	
Suburb: 	<DrCity>	Post Code: 	<DrPostcode>	
Phone: 	<DrPhone>	Fax:	<DrFax>	Mobile: 		
Email:		
Would you like to attend the initial appointment?	Yes		No		Unknown		

YOUNG PERSON’S MEDICAL INFORMATION 	
Does the YP have their own GP?	Yes		No		Unknown		
Details (name, practice, address, phone):		
Has the YP ever received prior Mental Health care or has had other worker involved in their care?	Yes		No		Unknown		
Details (please list service & duration):		
Does the YP have a Mental Health Care Plan (MHTP)?

PLEASE ATTACH A COPY if possible. Tick if Attached o	Yes		No		Unknown		
Date:		
Medicare Card?	Yes		No		Number/Other?	<PtMCNo>	

YOUNG PERSON’S CULTURE:	
Aboriginal		Torres Strait Islander		Both		Neither		Not Stated		Refugee		
Family of origin/nationality:	<Family of origin/nationality>	
Country of birth		
Arrival to Australia?	<Arrival to Australia>	
Languages Spoken at home?		
Risk of homelessness?	YES		NO		

REFERRAL DETAILS:	
What is the CURRENT concern regarding this young person?	

What does the YOUNG PERSON see as the problem?	

Duration of the current problem: 	

[MANDATORY FIELD] Current Risk Taking (suicide, self-harm, homicide, risk taking behaviours, drug & alcohol as well as any relevant history or past attempts): 	

Further details relevant to presenting problem (lives with, mood, appetite, sleep, home environment, education/employment, relationships) 	

What assistance would you like from headspace Hurstville? Please be SPECIFIC.	

The referrer agrees that all information submitted in this referral is an accurate reflection of the client’s support needs, is correct with no information withheld for the organization to fulfil its duty of care to clients, staff and other partner agencies.	

Referrer signature: _______________________________________________Date: <TodaysDate>	
NB: headspace aim to contact you regarding this referral within 3 working days.
If you have not heard from us, PLEASE call us ASAP.