hsdarwinpalmerston-making-contact-form

what we do

headspace Darwin and headspace Palmerston are here to support young people (aged 12-25) and their families to understand the available support options and to make choices that are right for now.

The team at headspace Darwin and Palmerston will review the information you provide on this form and someone will be in touch within 3 working days to discuss next steps.

If you are experiencing a mental health crisis, or are concerned for your safety/some else's safety please contact the NT Mental Health Line on 1800 682 288 for advice, or for immediate safety concerns contact 000

I would like to speak to someone at...

headspace Darwinheadspace Palmerston

I am... *

a young persona family membera friend

my first and last name

my relationship to young person

my best contact number *

my email

The young person knows I'm making contact?

YesNo

headspace is a voluntary service, all referrals require the young person's consent and awareness.

about me (young person's details)

my first and last name *

my date of birth *

my gender *

my preferred pronouns are...

he/himshe/herthey/themother

I identify as... *

AboriginalTorres Strait IslanderBothNeither

my preferred language (if not English)

I need an interpreter

YesNoSometimes

I'm staying at... (we require an address of where you are staying/ contactable even if not fixed) *

street address

suburb *

state/territory *

postcode *

I am 16 years old or younger... *

YesNo

trusted adult name

trusted adult contact number

best contact number *

my email address

I'm okay for a headspace survey to be sent to me via phone or email...

YesNo

Is there a family member/support who will be involved with appointments?

my family member/support person

my family member/support person's full name

their best contact details

the main thing I would like to change is.... (optional)

things that keep me strong, safe and help me to cope...

I am interested in... *

Welcome support (information about headspace service & what to expect)Aboriginal Social and Emotional Wellbeing SupportWork and Study SupportPhysical and Sexual Health SupportMental Health SupportAlcohol or Other Drug CounsellingEarly Psychosis (exploration of changes in how you perceive the world, confused thinking, unusual thoughts or ideas, behaviour that seems out of character)Peer worker supportI'm not sure

If this referral is specificially to access the GP Clinic at headspace Darwin you can contact 24/7 Med Care directly to book an appointment time on 139127

Peer Support Workers are trained to use their lived experience of mental health challenges and accessing services. They can support you by providing a non-clinical space to talk about your experiences or walk alongside you as you navigate services.

Aborignial Social and Emotional Wellbeing Workers use their cultural understandings and knowledge in their roles, supporting young people and families in receivi ng culturally appr opriate and safe support.

I have a mental health care plan...

YesNo

I have a medicare card and the number is...

email me a copy of this form

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