hsdarwinpalmerston-referral-form

what we do

headspace Darwin and headspace Palmerston support young people (aged 12-25) and their families using a choice focused approach.

We work to understand what is happening, and to provide support regarding the most apporpriate options and making choices that are right for now.

The clincial team at headspace Darwin and Palmerston will review the referral information you provide on this form and someone will be in touch within 3 working days

For children, adolescents and families with significant mental health concerns, including diagnostic assessment and treatment, please contact the Child and Adolescent Mental health team on 8999 4959 or contact NT Mental Health Line 1800 682 288 for 24hr emergency help for people in crisis, including parents/carers.

Preferred Location *

headspace Darwinheadspace Palmerston

young person details

first name *

last name *

date of birth *

gender *

Preferred pronouns

he/himshe/herthey/themother

Young person consents to referral *

headspace Darwin and headspace Palmerston are voluntary services, young people need to be aware and consenting

Please contact to discuss further if required

headspace Darwin 08 8931 5999

headspace Palmerston 08 8931 5900

cultural identity *

AboriginalTorres Strait IslanderBoth Aboriginal and Torres Strait IslanderNeither Aboriginal or Torres Strait Islander

Preferred language (if not english)

Interpreter required

YesNoSometimes

Home Address *

Street address *

City *

State *

Postcode *

Contact number

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

Family member/support person

Contact details

referrer details

Contact name *

Position title *

Organisation (if applicable) *

Best contact number *

email me a copy of this form

Brief information about main reasons for referral and the young person's goals for change

headspace service of interest *

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 ScreeningPeer worker support

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

Please send through details from the early psychosis checklist

Download Checklist

Upload Early Psychosis Checklist

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For young people experiencing suicide ideation/at risk of suicide NT Suicide Prevention short term therapy may be more appropriate please contact Connect to Wellbeing on 1800 844 054 or email NT.ConnectToWellbeing@neaminational.org.au to refer.

For crisis Mental Health Support contact the NT Mental Health Line 1800 682 288

Other relevant information

Upload any other relevant documents

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e.g. Safety plan, Mental health care plan

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