Referral Form

headspace is a free service for young people aged 12–25 years. headspace Albury Wodonga and headspace Wangaratta are programs of lead agency Gateway Health, supporting young people and their families across the community.

We provide a range of services, including mental health and wellbeing support, alcohol and other drug support, physical and sexual health (via Gateway Health Medical Practice and Clinic 35), work and study support, community engagement, education and awareness, cultural connections coordination, non-therapeutic social groups, and sexuality and gender support.

PLEASE NOTE: headspace Albury Wodonga and headspace Wangaratta are not an acute mental health/crisis service. If you have any immediate concerns regarding the safety and wellbeing for yourself or someone else, please contact one of the following services for assistance:

- Mental Health Triage Service - 1300 104 211

- Lifeline - 13 11 14

- Kids Helpline - 1800 55 1800

Please be advised headspace services are for young people between the ages of 12-25. You can access similar services through other Gateway Health services:

- Child & Family Health Counselling Services for young people under 12yrs - 02 6022 8888

- Head to Health Mental Health Supports for people over 25 - 1800 657 573

In an emergency, please call 000 immediately.

What is your relationship to the young person being referred? *

Do you consent for this referral to be sent to headspace? *

YesNo

Are you aged between 12-25 years of age? *

YesNo

headspace Albury Wodonga and headspace Wangaratta is a voluntary service for young people aged 12-25 years of age, please call our office on 1300 332 022 to discuss further options.

If you are under 16 years of age, have your parents or legal guardian consented to the referral? *

YesNoNot Applicable

Please provide the name and number of the consenting persons below

Consent Provided by *

Contact No. *

Relationship to you *

headspace Albury Wodonga and headspace Wangaratta is a voluntary service for young people aged 12-25 years of age. headspace can only engage if we have received consent to this referral.

If wanting to refer without parent or legal guardian consent under 16 years of age, please call our office on 1300 332 022 to discuss.

Referrer Details

Name *

Contact No. *

Organisation Name & Address

Does the referred young person give consent for this referral to be sent to headspace? *

YesNo

If the referred young person is under the age of 16, have the parents or legal guardian consented to the referral? *

YesNoNot Applicable

Consent Provided By *

Contact No. *

Relationship to Young Person *

headspace Albury Wodonga and headspace Wangaratta is a voluntary service for young people aged 12-25 years of age. headspace can only engage if we have received consent to this referral.

If wanting to refer without parent or legal guardian consent under 16 years of age, please call our office on 1300 332 022 to discuss.

You can reach out to headspace Albury Wodonga or headspace Wangaratta yourself; you don’t need anyone else to do it for you. If you’d prefer, a family member, carer, friend, GP, school, or another service can make the referral for you, as long as you know about it and give your consent.

If you’re under 16, we’ll need consent from a parent or guardian. If that’s tricky, just get in touch with us by phone, email, or drop into the centre and we’ll chat about other options together.

You can refer by visiting the centre (our staff can help you fill out the form), calling 1300 332 022, or by submitting this referral.

For centre opening hours, please visit our website:

- Albury/Wodonga - headspace.org.au/albury-wodonga

- Wangaratta - headspace.org.au/wangaratta

What happens next?

Once we receive your referral, our team will contact you (or your parent/carer if that’s who we need to speak with) within 2 business days to book a phone intake appointment. We aim to have that phone intake happen within two weeks of reaching out.

We’ll try a few times to get in touch to book your intake. If we don’t hear back, we’ll send you a text letting you know when to contact us by if you would like headspace support at this time. If you change your mind later that’s totally okay. You can refer again at any time.

We follow a “no wrong door” approach, which means you don’t have to worry about picking the “right” service straight away. If, after your phone intake, you decide another service feels like a better fit, our clinicians can support you with a referral so you're not navigating things on your own.

If someone else referred you, we’ll let them know once you’ve chosen your service option, or if we need to close the referral because we weren’t able to reach you.

If you referred yourself, we’ll only contact you, and we’ll let you know if your referral is closed due to no response.

Young people can refer themselves directly to headspace Albury Wodonga or headspace Wangaratta yourself, they don’t need anyone else to do it for them. If the young person prefers, a family member, carer, friend, GP, school, or another service can make the referral, as long as the young person knows about it and give their consent.

For young people under 16, we’ll need consent from a parent or guardian. If gaining consent if difficult, please contact us by phone, email, or by visiting the centre so we can talk through alternative options.

Referrals can be made by visiting the centre, calling 1300 332 022, or submitting this referral form.

For centre opening hours, please visit our website:

- Albury/Wodonga - headspace.org.au/albury-wodonga

- Wangaratta - headspace.org.au/wangaratta

After the Referral

Once we receive the referral, our staff will contact the young person (or your parent/carer, if appropriate) within 2 business days to book a phone intake appointment. We aim to schedule this intake within two weeks of first making contact.

We follow a 'no wrong door' policy, which means if the young person decides another service is a better fit after their phone intake, our clinicians will support them with a warm referral, so they feel supported throughout the process.

If you are completing this referral on behalf of the young person, you will be notified once a service option has been chosen, or if we close the referral because we were unable to reach the young person.

If the young person referred themselves, we will notify them directly if the referral is closed due to no response.

Information for Services

If you are a referring service and would like more information on headspace Albury Wodonga and Wangaratta, referral pathway and information on other local services, please check out this website.

Young people can refer themselves directly to headspace Albury Wodonga or headspace Wangaratta yourself, they don’t need anyone else to do it for them. If the young person prefers, a family member, carer, friend, GP, school, or another service can make the referral, as long as the young person knows about it and give their consent.

For young people under 16, we’ll need consent from a parent or guardian. If gaining consent if difficult, please contact us by phone, email, or by visiting the centre so we can talk through alternative options.

Referrals can be made by visiting the centre, calling 1300 332 022, or submitting this referral form.

For centre opening hours, please visit our website:

- Albury/Wodonga - headspace.org.au/albury-wodonga

- Wangaratta - headspace.org.au/wangaratta

After the Referral

Once we receive the referral, our staff will contact the young person (or your parent/carer, if appropriate) within 2 business days to book a phone intake appointment. We aim to schedule this intake within two weeks of first making contact.

We follow a 'no wrong door' policy, which means if the young person decides another service is a better fit after their phone intake, our clinicians will support them with a warm referral, so they feel supported throughout the process.

If you are completing this referral on behalf of the young person, you will be notified once a service option has been chosen, or if we close the referral because we were unable to reach the young person.

If the young person referred themselves, we will notify them directly if the referral is closed due to no response.

Information for Services

If you are a referring service and would like more information on headspace Albury Wodonga and Wangaratta, referral pathway and information on other local services, please check out this website.

Your Details

First Name *

Last Name *

Preferred Name

Preferred Pronouns

Date of Birth *

Gender Assigned at Birth

Do you identify as LGBTQIA+?

YesNoPrefer not to say

How would you like us to record your Gender Identity?

Contact No. *

Email Address *

Home Address *

Street address *

City *

State *

Postcode *

Please provide details of preferred safe contact method

First Nations Status

Mob

Country of Birth *

Refugee Status

YesNoPrefer not to say

Main Language Spoken at Home *

Preferred Language

Interpreter Required

Medicare Card Number

Expiry Date

Concession Card Holder

YesNoUnknown

Card Type

Expiry Date

Do you live with a Disability?

YesNoPrefer not to say

Please Select

Are there any needs/preferences that would assist you?

Do you have a regular GP?

YesNo

If yes, please provide details below

Name of GP

Contact No.

Name of Clinic

Are there any Court Orders we may need to keep in mind while supporting?

Family Court OrdersIVO/AVOOther - please specifyNot Applicable

Please provide a brief description

Are there any custody arrangements for the household that may impact participation with our services?

YesNo

Please provide a brief description

Emergency Contact

Full Name *

Contact Number *

Relationship to You *

Young Person's Details

First Name *

Last Name *

Preferred Name

Preferred Pronouns

Date of Birth *

Gender Assigned at Birth

Do you identify as LGBTQIA+?

YesNoPrefer not to say

How would you like us to record your Gender Identity?

Contact No. *

Email Address *

Home Address *

Street address *

City *

State *

Postcode *

Please provide details of preferred safe contact method

First Nations Status

Mob

Country of Birth *

Refugee Status

YesNoPrefer not to say

Main Language Spoken at Home *

Preferred Language

Interpreter Required

Medicare Card Number

Expiry Date

Concession Card Holder

YesNoUnknown

e.g. Health Care Card, Pension

Card Type

Expiry Date

Does the Young Person Live with a Disability?

YesNoUnknown

Please Select

Are there any needs/preferences that would assist the Young Person?

Does the young person have a regular GP?

YesNoUnknown

If yes, please provide details below

Name of GP

Contact No.

Name of Clinic

Are there any Court Orders we may need to keep in mind while supporting?

Family Court OrdersIVO/AVOOther - please specifyNot Applicable

Please provide a brief description

Are there any custody arrangements for the household that may impact participation with our services?

YesNo

Please provide a brief description

Emergency Contact

Full Name *

Contact Number *

Relationship to Young Person *

Young Person's Details

First Name *

Last Name *

Preferred Name

Preferred Pronouns

Date of Birth *

Gender Assigned at Birth

Do you identify as LGBTQIA+?

YesNoPrefer not to say

How would you like us to record your Gender Identity?

Contact Number *

Email Address *

Home Address *

Street address *

City *

State *

Postcode *

Please provide details of preferred safe contact method

First Nations Status

Mob

Country of Birth *

Refugee Status

Yes NoPrefer not to say

Main Language Spoken at Home *

Preferred Language

Interpreter Required

Medicare Card Number

Expiry Date

Concession Card Holder

YesNoUnknown

e.g. Health Care Card, Pension

Card Type

Expiry Date

Does the Young Person live with a Disability?

YesNoUnknown

Please Select

Are there any needs/preferences that would assist the Young Person?

Does the young person have a regular GP?

YesNoUnknown

If yes, please provide details below

Name of GP

Contact No.

Name of Clinic

Are there any Court Orders we may need to keep in mind while supporting?

Family Court OrdersIVO/AVOOther - please specifyNot Applicable

Please provide a brief description

Are there any custody arrangements for the household that may impact participation with our services?

YesNo

Please provide a brief description

Emergency Contact

Full Name *

Contact Number *

Relationship to Young Person *

Referral Details

Which Centre would you like your appointments at? *

Albury Wodonga - 155 High Street, WodongaWangaratta - 44 Rowan Street, Wangaratta

Substance/s Used *

Frequency/Amount *

Intravenous (IV) Use? *

YesNo

What do you hope headspace can support with? *

Other Diagnoses or Concerns

Please provide further details *

Is the other service aware of the referral to headspace?

YesNo

Will the services involved continue working with the young person?

YesNo

Will the services involved continue working with the you?

YesNo

Referrer's Signature *

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Young Person's Signature *

Draw signature|Type signatureClear

Referral Date *

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