Online Referral Form
headspace Onkaparinga is operated by
Sonder
Are you:
Referring yourself
Referring someone else
Referrer Details
Is the young person aware of this referral:
Yes
No
Please reflect on your right to refer the young person and please let the young person know about this referral
Young Person Details
Gender
Male
Female
Non Binary
Questioning
Intersex
Gender diverse and / or transgender
Prefer no to say
Date of Birth (DD/MM/YYYY)
As the young person is under 16 years, is the parent or carer aware of the referral?
As you are under 16 years, is your parent or carer aware of the referral?
Yes
No
Do you have Medicare Card?
Does the young person have a Medicare Card?
This is very useful information for care provided so please complete this information where possible
Yes
No
Medicare Card Details
Do you have an NDIS plan?
Does the young person have an NDIS plan?
Yes
No
No
What NDIS services typically purchase using the plan:
Preferred mode of contact
SMS
Email
Letter
Mobile phone call
Is that ok to send mail to provided address?
Yes
No
Emergency Contact Name
Emergency Contact Phone
Relationship to young person
Do you Identify as Aboriginal or Torres Strait Islander
Does the young person Identify as Aboriginal or Torres Strait Islander
Yes
No
Would you like to be linked with an Aboriginal and Torres Strait Islander Peer Support Worker
Does the young person would like to be linked with an Aboriginal and Torres Strait Islander Peer Support Worker
Yes
No
Do you Identify as of a Culturally and Linguistically Diverse Background?
Does the young person Identify as of a Culturally and Linguistically Diverse Background?
Yes
No
Please provide the main cultural identify:
Is an Interpreter required?
Yes
No
Do you currently have NDIS Funding and/or are linked with an NDIS Provider?
Does the young person currently have NDIS Funding and/or are linked with an NDIS Provider?
Yes
No
Please provide the language required for interpreter services:
Reasons for referral
Please give us as much information as possible, so we can learn more about the young person
Please give us as much information as possible, so we can learn more about you.
How has this impacted day-to-day life?
How long has this been going on for?
Please indicate if any of the following areas are a concern
Pregnancy or young parent
Mental Health
Family Issues
School Issues
Gender Identity
Trauma
Physical or sexual health
Behaviour
Alcohol and other drugs
Work and Education Options
Body Image or Eating
Culture, cultural loss/loss of country
Are you having any CURRENT (within the last week) thoughts about suicide?
Is the young person having any CURRENT (within the last week) thoughts about suicide?
Yes
No
Thank you for sharing the young person's information with us, because you have answered YES to the last question we suggest you seek help for the young person from a crisis support service.
If the young person is in a crisis or emergency situation please contact Mental Health Triage on 13 14 65 or your local hospital or 000.
If the young person are in a safe position, feel free to call us on 8186 8600 to discuss if we are the best support for you. Please note that we are not an emergency service, and might not get back to the young person or you as quickly as Mental Health Triage can. If you would still like to proceed with your referral then please click follow option:
Proceed
Thank you for sharing your information with us, because you have answered YES to the last question we suggest you seek help from a crisis support service.
If you are in a crisis or emergency situation please contact Mental Health Triage on 13 14 65 or your local hospital or 000.
If you are in a safe position, feel free to call us on 8186 8600 to discuss if we are the best support for you. Please note that we are not an emergency service, and might not get back to you as quickly as Mental Health Triage can. If you would still like to proceed with your referral then please click follow option:
Proceed
.
Have you had any prior suicide attempts?
Has the young person had any prior suicide attempts?
Yes
No
Have you self harmed within the last two weeks?
Has the young person self harmed within the last two weeks?
Yes
No
Have you accessed other support for these concerns before? If so, which types
Has the young person accessed other support for these concerns before? If so, which types
This is my first time accessing support
headspace Onkaparinga
A different headspace centre
A private psychologist
Other
Doctor Details
Is there anything else we might need to know when providing services to you?
Is there anything else we might need to know when providing services to this young person?
Please attach any relevant documentation (Mental Health Care Plan, Discharge Summary, Assessments)
Choose File
No file selected
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No file selected
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No file selected
How did you hear about headspace?
General practitioner (GP) / doctor
A family, friend or carer
headspace website
Sonder website
headspace social media, such as Facebook or Instagram
headspace attendance at event
headspace workshop or presentation
Another service provider
A school counsellor
Other (please specify)