Community Referral Form
GPs to complete Mental Health Treatment Plans (MHTP) - not required for Early Psychosis
For any inquiries, please contact us on 1800 063 267
Please fax referrals to headspace Adelaide on 1800 632 193

Young Person's Details
Name: Patient Demographics.Full Name | DOB: Patient Demographics.DOB
Address: Patient Demographics.Full Address
Is it okay for us to send headspace branded documents to this address? Documents
Phone: (m) Patient Demographics.Phone (Mobile) (h) Patient Demographics.Phone (Home) | Email: Patient Demographics.E-mail
Gender: Patient Demographics.Gender | Preferred Pronouns: Preferred Pronouns | Medicare No: Patient Demographics.Medicare Number | Exp. Patient Demographics.Medicare Expiry Date
Next of Kin/Emergency Contact: Patient Demographics.Emergency Contact Name | Phone: (m) Patient Demographics.Emergency Contact Mobile Phone (h) Patient Demographics.Emergency Contact Home Phone
Does the young person require an interpreter? Interpreter | If yes, which language? Language
Does the young person identify as Aboriginal or Torres Strait Islander? ATSI Status
Does the young person have an existing GP? Existing GP | Does the young person have an existing MHTP? existing MHTP
Practice Name (if applicable): Practice.Name
Doctor's Name (if applicable): Treating Doctor.Name
Referrer's Details
Name: Referrer's Name | Phone: Referrer's Phone
Email: Referrer's Email
Relationship to young person (organisation if applicable): Relation to person
Important information about your referral

headspace is a service for young people aged 12-25.We can only engage with young people who have provided consent to the referral.      
If young person is unable to provide informed consent due to mental state (e.g. psychosis), please contact us.

headspace Adelaide is not a crisis service and should you have any concerns, if the young person is in crisis, or if they are at an acute risk of harming themselves or others, please contact emergency services on 000. In a mental health emergency, please contact Mental Health Triage on 13 14 65

The receipt of the referral form does not indicate acceptance to headspace Adelaide. Suitability of the referral will be determined following assessment with the young person. Please contact us on 1800 063 267 to confirm receipt and discuss the outcome of your referral.

To provide a complete referral, please attach any relevant assessment notes, discharge summaries and/or additional information. We will endeavour to respond to referrals within 24-48 business hours, but if you have any queries pertaining to our referral, please phone us using the contact details above.

Consent
Does the young person consent to this referral? | Consent

Office Use Only
Appointment booked:  HDSP / MBS / GP / MATT / CCT | Date: | Time:
Referred elsewhere (details):
Person completing this form: |

The headspace Adelaide Primary Platform offers early intervention, short term support for young people experiencing mild to moderate mental health difficulties. Other services include, GPs, Drug & Alcohol Counselling and Vocational and Educational Support programs. | The headspace Adelaide Youth Early Psychosis Program (hYEPP) provides a multidisciplinary, early intervention service for young people experiencing, or at risk of developing, a first episode of psychosis.
Is this referral for the Primary Platform? Primary Platform | Is this referral for the Youth Early Psychosis Program? Psychosis Program

Reason for Referral
What are some of the current issues? (please include info about duration, age of onset and pre-existing diagnoses):
Current Issues
What has been the impact of these? (e.g. relationships, school, work, home etc.):
Impact of Issues
What are the young person's goals and objectives?
Person's Goals
Is there any family history of mental health conditions?
Family History
Is the young person currently supported by other health services? (If so, please provide service details below) Using other services
Does the young person consent to headspace Adelaide exchanging information with these services to support this referral? (If so, please provide contact details below) Consent to exchange
Services and Consent
Risk Factors (referrer to complete)
Suicide | Suicide Risk
Non-suicidal self-injury | Self-injury Risk
Harm to Others | Harm to Others Risk
Vulnerability | Vulnerability Risk
Other Risk Factors? (e.g. homelessness, social withdrawal, medication compliance)
Other Risk Factors?