hsdarwinpalmerston-referral-form

what we do

headspace Darwin and headspace Palmerston support young people (12-25 years) and their families using a choice focussed approach. We offer support with mental health, physical & sexual health, alcohol & other drugs and work & study.

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 on 1800 682 288 for 24 hour emergency help for people in crisis, including parents/carers.

Preferred Location *

headspace Darwinheadspace Palmerston

young person details

First Name *

Last Name *

Preferred Name

Date of Birth *

Gender *

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 to a referral to our services.
Please contact us to discuss further, if required, on headspace Darwin (08) 8931 5999 or headspace Palmerston (08) 8931 5900.

Preferred Language (if not English)

Interpreter Required

YesNoSometimes

Home Address *

Street Address *

City *

State *

Postcode *

Is it safe to send mail to this address?

YesNo

Contact Number

Who does this phone number belong to (if not the young person)?

Is it safe to leave a voicemail or SMS on this number?

YesNo

Is there a family member/support who will be involved with appointments?
*If young person is 16 years or under please ensure an adult is listed to support referral.

Family Member / Support Person Name

Relationship to Young Person

Contact Details

referrer details

Contact Name *

Position Title *

Organisation (if applicable) *

Best Contact Number *

email me a copy of this form

Main reasons for referral and the young person's goals for change

headspace Service of Interest *

Welcome Support (information about headspace services & what to expect)Aboriginal Social and Emotional Wellbeing SupportWork and Study SupportPhysical and Sexual Health SupportMental Health SupportAlcohol or Other Drug CounsellingEarly Psychosis ScreeningAttend a Group Peer Worker Support

If this referral is specifically to access the GP Clinic (operating from headspace Darwin) you can contact 24/7 Med Care directly to book an appointment on 13 91 27.

If you would like more information about our groups, please contact us on 8931 5999.

Please download and complete the Early Psychosis Checklist

Download Checklist

Upload Early Psychosis Checklist

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Please include information about any safety planning you have completed with the young person and family.

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 on 1800 682 288.

Other Relevant Information

Upload Any Relevant Documentation

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e.g. Safety Plan, Mental Health Care Plan

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