headspace Adelaide Online Referral Form

Gender

Male

Female

Non Binary

Questioning

Intersex

Gender diverse and / or transgender

Prefer no to say

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

Medicare Card Details

Do you have an NDIS plan? Does the young person have an NDIS plan?

Yes

Unsure

What NDIS services typically purchase using the plan:

Preferred mode of contact

SMS

Letter

Mobile phone call

Is that ok to send mail to provided address?

Yes

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

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

Please provide the main cultural identify:

Is an Interpreter required?

Yes

Please provide the language required for interpreter services:

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 and Alcohol Counselling, and Vocational and Educational Support programs.

Is this referral for the Primary Platform?

Yes

The headspace Adelaide Youth Early Psychosis Program 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 Early Psychosis Program?

Yes

Please note: Referrals to the Ultra High Risk (UHR) stream of the headspace Early Psychosis program are currently paused due to capacity limits. The pause will be in place from Tuesday 10 June to Monday 8 September 2025. Referrals to the First Episode Psychosis (FEP) stream remain open. If you’re unsure which stream is appropriate, before submitting the referral, please contact the Mobile Assessment and Treatment Team on 1800 063 267 or email info@headspaceadelaide.org.au

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

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

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 1800 063 267 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 1800 063 267 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

Have you self harmed within the last two weeks? Has the young person self harmed within the last two weeks?

Yes

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 Adelaide

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?

1. The Primary Platform is currently experiencing high demand - we can see you sooner in this program if you obtain a Mental Health Treatment Plan from a GP. If you would like some more information about this please contact us on 1800 063 267. Please attach a copy of your Mental Health Treatment Plan if you have one.
2. Please attach any relevant documentation (Discharge Summary, Assessments)

Choose File

No file selected

Choose File

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)

Online Referral Form

Referrer Details

Young Person Details

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 you are in a crisis or emergency situation please contact Mental Health Triage on 13 14 65 or your local hospital or 000.