REFERRAL FORM
ELIGIBILITY CRITERIA:
 Referrals from QLD Health require a copy of ALL relevant collateral information (including assessment, discharge
summaries & recovery documents) prior to the referral being processed.
 Referrals from Probation and Parole require information on convictions and pending legal matters including dates,
along with AOD information prior to referral being processed.
REFERRER (INDIVIDUAL COMPLETING THIS DOCUMENT)
Contact Name:
Position / Relationship:
Organisation (if applicable):
Postal Address:
Post Code
Phone:
Fax:
Signed:
Mobile:
Email:
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__
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PRIMARY REASON (S) FOR REFERRAL
Short-term Mental health intervention with headspace Primary Care Team
Assessment with headspace Youth Early Psychosis Program (YEPP)
Mental health
Alcohol/Drug
Physical
Vocational
Other
PERSON BEING REFERRED (THESE DETAILS WILL BE USED TO CONTACT THE YOUNG PERSON / PARENT, GUARDIAN)
FIRSTNAME:
SURNAME:
______
Date of Birth:
___
Age: ________
Gender:
M
F
Other
Address:
_______________________________________
Suburb:
__________________________
Postcode:
____ State: ______________
Home Ph:
Mobile:
___
If consent provided by young person please provide details of their parent/ guardian:
__
AUTHORISATION OF REFERRAL BY PERSON BEING REFERRED
Please NOTE: Referrals will not be processed without signed consent.
I am aware that this referral is being made. I understand that I can withdraw from this referral or from the referred service
at any time.
I give permission for headspace Southport to use my contact details above for future contact with me. Yes
No
I give permission for the staff of headspace Southport to obtain relevant information from government and nongovernment agencies, from doctors and other health professionals specifically relevant to my care whilst being a client of
headspace Southport.
Signed: _______________________________ Print Name: ________________________ Date: ________________
If under 18 years of age authorization ideally should be provided by a parent/ guardian.
Parent/ Guardian Signed:
Print Name:
__ Relationship:
_______________
Risk to self or others (Include self harm/ suicide attempts, violence, threats of violence)
Date
Type of Behavior
Reason for Behavior
Outcome/ Treatment Provided
Other Agencies / health care providers currently involved within the individuals care: (EG: Government, non
Government, GP’s, Psychiatrists, and Community Services)
Name of Organisation
Contact Person
Address
Phone
PRESENTING ISSUES
ANXIETY
REFUSING SCHOOL
DEPRESSION
SELF HARM
HARM OR THREATS TO OTHERS
STRESS
SUICIDAL
CRYING
DIFFICULTY SLEEPING
DRUG ABUSE
ALCOHOL ABUSE
LOW SELF ESTEEM
OTHER
PAIN MANAGEMENT ISSUES
FAMILY PROBLEMS
PHYSICAL ABUSE
RELATIONSHIP ISSUES
SEXUAL ABUSE
DOMESTIC VIOLENCE
EMOTIONAL ABUSE
HALLUCINATIONS AND DELUSIONS
EATING PROBLEMS
BODY IMAGE
BULLYING OTHERS
PENDING LEGAL MATTERS
IF ANY BOXES ABOVE HAVE BEEN TICKED PLEASE PROVIDE DETAILED INFORMATION ON PAGE 3
ADHD / ADD
FINANCIAL DIFFICULTY
LOSS OF APPETITE
PHYSICAL DISABILITY
INTELLECTUALLY IMPAIRED
PTSD / TRAUMA HISTORY
SOCIAL PROBLEMS AT SCHOOL
ASPERGERS / AUTISM
HISTORY OF HOSPITALISATION
PRESENTATION TO ED OR HOSPITAL
PAST OR PRESENT CONTACT WITH DOCS
FUNCTIONAL DECLINE
Summary of the Young Person to be completed by Referrer
Below are the areas headspace Southport will assess when the young person attends their first
appointment. To help us assist the young person, could you please outline any pertinent information you are
aware of, under the relevant heading.
Home and Environment
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Education and Employment:
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Activities and Friends:
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Drugs and Alcohol:
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Relationships and Sexuality:
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Conduct Difficulties and Risk-Taking:
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Anxiety and Eating:
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Depression and Suicide:
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Psychosis and Mania:
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Please fax referral form to headspace Southport Access Team – 07 55 271 251