hsKatherine-making-contact-form

what we do

headspace Katherine is 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 Katherine 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 you 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

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

Preferred language (if not english)

I need an interpreter

YesNoSometimes

I'm staying at...(please provide best contact location even if not fixed) *

where I am staying/ address *

suburb/community *

state/territory *

postcode *

I am 16 years old or younger... *

YesNo

trusted adult name (and relationship to young person)

trusted adult contact number

best contact number *

my email address

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

YesNo

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

my family member/support person

their best contact details

my main issue/concern right now...

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

I am interested in... *

Welcome support (information about headspace facilitated by our community engagement worker)Aboriginal Social and Emotional Wellbeing Support (tick for more info)Work 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

I have a mental health care plan...

YesNo

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

email me a copy of this form

Save and Complete Later