hsKatherine-referral-form

what we do

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

The clinical team at headspace Katherinewill review the referral information you provide on this form and someone will be in touch within 3 working days. Our team can be contact on 08 8912 4000.

For children, adolescents and families with significant mental health concerns, including diagnostic assessment and treatment, please contact the Katherine Mental Health Team to discuss on 08 8973 8724 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 Katherine hubtelehealth online school or community outreach

young person details

First Name *

Last Name *

Preferred Name

Date of Birth *

Gender *

Pronouns

he/himshe/herthey/themother

Young person consents to referral *

headspace Katherine is a voluntary service.

Young people need to be aware and consenting to a referral to our services.

Please contact us to discuss further if required on 08 8912 4000.

Preferred Language (if not English)

Interpreter Required

YesNoSometimes

Home Address *

Street Address *

Suburb/Community *

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 service and what to expect)Aboriginal Social and Emotional Wellbeing SupportWork and Study SupportPhysical and Sexual Health SupportMental Health SupportAlcohol or Other Drug CounsellingPeer Worker Support

Please include information about 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

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e.g. Safety Plan, Mental Health Care Plan

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