headspace Box Hill Professional Referral Form

Thank you for referring your client to headspace Box Hill. This form is for professionals 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 family or friends of a young person wanting to refer someone to headspace Box Hill please use our Family and Friends 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.

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

Referrer Details

Please note: making a referral to headspace does not guarantee the suitability of our service. Please do not close your work with the Young Person until you have been informed we will accept the referral.

What is your name? *The name of the person making the referral

What is the name of your organisation? *

What is your best contact phone number? *

What is your email address? *

What best describes your relationship with the Young Person? *

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? *

YesNo

Please note that headspace Box Hill will not be able to process this referral if the young person doesn't consent to it. You are welcome to contact us via 03 9810 9310 for a secondary consultation.

What the Young Person's First Name? *

What is the Young Person's Last Name? *

What is the Young Person's preferred name?

What is the Young Person's date of birth? *headspace Box Hill supports young people aged between 12 - 25. If the young person is outside of this age range, please contact us at 03 9810 9310 for more information.

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

What is the Young Person's current home address? *

How does the Young Person describe their gender?

What is the Young Person's gender?

What pronouns does the Young Person use?

What are the Young Person's pronouns

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 *

Emergency Contact Email

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?

Yes No Maybe

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 especially related to risk.

Please attach any supporting documents here:

Browse

Thank You for your Referral

Once you submit this form, you consent to headspace Box Hill contacting you. A confirmation text message will be sent to the Young Person acknolwedging the referral.

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

Please note: making a referral to headspace does not guarantee the suitability of our service. Please do not close your work with the Young Person until you have been informed we will accept the referral.

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