headspace Box Hill Family & Friends Referral Form

Thank you for referring your family member or friend to headspace Box Hill. This form is for family and friends to refer young people to this service. headspace is a service for young people aged 12-25.

If you would like to refer yourself to headspace Box Hill please use our Self Referral Form, if you are a professional wanting to refer someone else to headspace Box Hill please use our Professional Referral Form or alternatively call our friendly team on 9810 9310.

headspace Box Hill is managed by Mind Australia as the lead agency. Your referral will be viewed by the Intake and Assessment team to determine which supports will best meet your needs. All your information is private and confidential and all information you submit on this form, is stored on a secure server.

This form will take approximately 10 minutes to complete.

Before proceeding with this referral form please ensure you have read "What you need to know" document.

We are not a crisis service. If you are concerned for your or someone else's safety, please contact 000 immediately or call your local Mental Health Triage Service.

Eastern Mental Health Triage 1300 721 927 (Maroondah, Knox, Yarra Ranges, Manningham, Whitehorse and Monash)

St Vincent’s Mental Health Triage 1300 558 862 (Yarra & Boroondara)

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

Beyondblue (24/7): 1300 224 636 or webchat at beyondblue.org.au

Suicide Call Back Service (24/7): 1300 659 467 or webchat at suicidecallbackservice.org.au

Consent for Service

To process this referral and determine which supports will meet your needs best headspace Box Hill will need to collect some information about you. This information will be accessible to the headspace Intake and Assessment team working on your referral. We will securely record any information you provide, and it will only be shared where we are required to by law or with your permission.

Please read the "What you need to know" document before proceeding.

I acknowledge I have read the "What you need to know" document and consent to the collection, storage and use of my personal information by headspace Box Hill to support this referral?

*

Referrer Details

What is your name? *The name of the person making the referral or the name of the person completing this form

What is your best contact phone number? *

What is your email address? *

What best describes your relationship with the Young Person? *Example: Parent, Friend, Partner, Teacher

Young Person's Details

The information in this section is required to process this referral. If you prefer you can call the centre on 9810 9310 to make a referral over the phone.

headspace Box Hill is a voluntary service and we only accept referrals where the Young Person is aware and consenting to this process

Does the Young Person consent to this referral being made on their behalf?

*

What the Young Person's First Name? *

What is the Young Person's Last Name? *

What is the Young Person's date of birth? (DD/MM/YY) *

What is the best contact number for the Young Person? *

What is the Young Person's current home address?

What is the Young Person's Email Address? *

If the Young Person is under 18yrs, are there any shared care arrangement or court orders with parents? *

YesNoUnsure

Emergency Contact Details

Emergency Contact Name *

Emergency Contact Number *

If we are required to contact this person, is there anything we should be aware of?

Demographic Information

This information is not required however it helps us to determine your support needs

Does the Young Person identify as Aboriginal and/or Torres Strait Islander?

Does the Young Person identify as LGBTQIA+?

YesNoUnsurePrefer not to answer

Does the Young Person require the services of an interpreter?

YesNoUnsure

Language/Dialect required?

Is the Young Person at risk of becoming homeless?

YesNoMaybe

Does the Young Person have any communication or access needs?

YesNoMaybe

Accessibility needs required?

Today's referral

Why are you making this referral today? *Please include all information that you feel would be beneficial for us to know about this referral.

Thank You for your Referral

Once you submit this form, you consent to headspace Box Hill contacting you.

The Intake & Assessment team will make every effort to contact the referrer within 3 business days.

headspace Box Hill 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:

Eastern Mental Health Triage 1300 721 927 (Maroondah, Knox, Yarra Ranges, Manningham, Whitehorse and Monash)

St Vincent’s Mental Health Triage 1300 558 862 (Yarra & Boroondara)

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

Beyondblue (24/7): 1300 224 636 or webchat at beyondblue.org.au

Suicide Call Back Service (24/7): 1300 659 467 or webchat at suicidecallbackservice.org.au