Group Registration 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 of a young person, 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.

Privacy and Confidentiality

headspace Albury Wodonga and headspace Wangaratta will use the information collected in this form to assist with the administration of the social group, and in case of any emergencies. This information will be stored electronically in a secured format and only be used by those involved in administering and facilitating the social group, which may include external facilitators hired by headspace Albury Wodonga or headspace Wangaratta to deliver a workshop. For more information about Privacy, please see our Information Privacy policy and Privacy Statement, available on the Gateway Health website.

Child Safe Standards

In line with the Child Wellbeing and Safety Amendment (Child Safety Standards) Act 2015, Gateway Health is committed to upholding the Victorian Child Safe Standards, to the best of its abilities and resources. Gateway Health upholds itself as an organisation committed to the participation and empowerment of all children.  More information about Gateway Health’s Commitment to Child Safe Standards, is available on the Gateway Health website.

Group Participation Information

headspace Albury Wodonga & headspace Wangaratta run several non-therapeutic social groups for young people aged 12-25 years old. These groups include:

Northeast Social Group - for participants aged 17 to 25 years old. Activities include nature walks, hiking, fruit picking, picnics, cooking, games afternoons, crafternoons and more!
QREW - is for young people aged 12 to 17 years old and connects through the Victorian school term fortnightly on Wednesdays from 4pm - 5:30pm. 
Queer Connections - gives young people aged 18 to 25 the change to connect with others in the community and also get involved in events!
Dungeons and Dragons – for ages 12 to 17 and 18 to 25. These groups run fortnightly on Thursday.

For up to date information on headspace Albury Wodonga & headspace Wangaratta social groups, please check out our website.

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

Full Name

Contact Number

Organisation Name

Do you consent for headspace to process this registration? *

YesNo

Has consent been provided for headspace to process this registration? *

YesNo

Aged between 12-25 years old? *

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 aged outside of this age range.

Further Details

If under 16 years of age, has consent been provided for this registration from Parents or Legal Guardian? *

YesNoNot Applicable

Consent Provided by *

Relationship to young person *

Contact No. *

Email *

Details of Young Person

First Name *

Last Name *

Preferred Name

Preferred Pronouns *

Date of Birth *

Sex 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 *

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?

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 *

Address *

Street address *

City *

State *

Postcode *

Health and Wellbeing

Please select at least one of the above and provide any further details regarding access needs, disabilities, or health conditions *

Are there any specific accessibility needs?

Are there any Allergies we should be aware of?

Young Person's Signature *

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Date

Referrer's Signature *

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Date

Parent/Guardian Consent for young people under 16 years of age

By signing below, I agree to and understand the following:

I understand and acknowledge that the group is not a therapeutic support group and that it does not provide clinical or therapeutic interventions.
I understand that Gateway Health is not responsible for the supervision or safety of participants before or after attending the group.
If, as a guardian, I suspect that my young person is struggling with their mental health, I understand the importance of seeking clinical support. This may involve consulting with mental health professionals, therapists, or relevant healthcare providers to ensure the wellbeing of my young person.
I have provided all relevant and accurate details for the young person to participate in this program.

Consent to the use of images for young person(s) under 18yrs old:

Before Gateway Health uses any image (photograph or video) we must have your permission. The images may be used by the organisation for any educational or promotional material in print and/or digital format including our website and social media channels.

I, as the legal guardian hereby:

Give my consent for headspace to collect and store the personal information of the named child/young person, in accordance with their Privacy Statement and the Privacy Act, available on Gateway Health’s website. *

Give my consent for the named child/young person to participate in the group   *

Give my consent for the use of the named child/young person’s image. 

Do not give my consent for the use of the named child/young person’s image. 

Full Name *

Parent/Guardian Consent *

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Date *

Consent for Independent Departure of Young Person

I, as the legal guardian, hereby give my consent for the named young person(s) to independently depart locations visited by the group or to arrange their own transportation home after participating in the group. Occasionally, groups may travel to local areas e.g. cinemas, bowling, however common ongoing location include:

Murray Art Museum Albury (MAMA), 546 Dean Street, Albury NSW 2640
Windbreak 3690, 198a High Street, Wodonga Vic 3690
Gateway Health, 155 High Street, Wodonga Vic 3690

Full Name

Parent/Guardian's Signature

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Date

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