hsKatherine-making-contact-form

what we do

headspace Katherine is here to support young people (12-25 years) and their families. We offer support with mental health, physical & sexual health, alochol & other drugs and work & study.

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

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 Katherine telehealth onlineschool or community outreach

I am... *

a young person a family membera friend

my first and last name

my best contact number *

my relationship to young person

The young person knows I'm making contact?

YesNo

headspace is a voluntary service, all referrals require the young persons awareness and consent.

about me (young person's details)

my first and last name *

preferred name

my date of birth *

my gender *

my pronouns are...

he/himshe/herthey/themother

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) *

where I am staying / address *

suburb/community *

state/territory *

postcode *

is it safe to send mail to this address?

YesNo

best contact number *

who does this number belong to (if not yours)?

my email address

is it safe to leave a voicemail or sms on this number?

YesNo

I'm okay for a headspace survey to be sent to my phone number...

YesNo

I am 16 years old or younger... *

YesNo

trusted adult name (and relationship to me)

trusted adult contact number

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

my family member / support person name

their relationship to me

their best contact details

reason for making contact

the main thing I would like to change or get out of coming to headspace is... *

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

I am interested in... *

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 CounsellingPeer Worker SupportI'm not sure

Aboriginal Social and Emotional Wellbeing Workers utilise their cultural understanding and knowledge to provide culturally appropriate and safe support to young people and families.

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.

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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