hsKatherine-referral-form

what we do

headspace Katherine supports 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 appropriate options and making choices that are right for now.

The team at headspace Katherine will 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 Katherine Mental Health Team to discuss 08 8973 8724

Please call the NT Mental Health Line 1800 682 288 for 24hr emergency help for people in crisis, including parents/carers.

Preferred Location *

headspace Katherine hubtelehealth online school or community outreach

young person details

Name *

Date of birth *

Gender *

Preferred pronouns

he/himshe/herthey/themother

Young person consents to referral *

headspace Katherine is a voluntary service.

Please contact us to discuss further if required.

on 8912 4000

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 *

Suburb/Community *

State *

Postcode *

Contact number

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

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 facilitated by our community engagement worker)Aboriginal Social and Emotional Wellbeing SupportWork and Study SupportPhysical and Sexual Health SupportMental Health SupportAlcohol or Other Drug Counselling

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 1800 844 054 / NT.ConnectToWellbeing@neaminational.org.au

Other relevant information

Upload any other relevant documents

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e.g. Safety plan, Mental health care plan

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