Self Referral

You can get support for your mental health by creating a headspace account at headspace.org.au, or you can speak to someone 1-on-1 via online chat, email or over the phone at eheadspace.org.au or 1800 650 890

If you are in immediate risk, please contact Bendigo Psychiatric Triage on 1300 363 788, this number is contactable 24 hours a day, 7 days a week or call 000.

If you need to speak to someone urgently:

Lifeline 13 11 14

Kids Helpline 1800 551 800

Suicide Call Back Service 1300 659 467

Please note: We are currently NOT accepting referrals for ADHD assessments

Are you between the ages of 12 and 25? *

YesNo

Please be advised headspace services are for young people between the ages of 12-25. You can access similar services through the following Bendigo Community Health Services - https://www.bchs.com.au/ Head to Health- 1800 595 212

Consent

Do you consent to having an Electronic Medical Record created at headspace Bendigo? *

YesNo

In order for us to provide care to you, it is a service requirement that you have an electronic medical record with us.

Referral

Are you referring yourself? *

YesNo

Have you seen anybody at headspace Bendigo before? *

Yes No

If you are under 16 years old, are your parents/carer aware of this referral? *

YesNoN/A

If you are in school, which school do you attend? *

Are there any alerts you would like to put on your file? For example; no parent contact, no letters home ect.

First name *

Last name *

Affirmed name

Date of birth *Please be advised headspace services are for young people between the ages of 12-25. You can access similar services through the following Bendigo Community Health Services - https://www.bchs.com.au/ Head to Health- 1800 595 212

Gender *

Male Female Non binaryOther

Please specify

Do you identify as Aboriginal or Torres Strait Islander? *

Allergies *

Address *

Phone number *

Email *

Medicare card numberPlease include IRN, this is the number next to your name

Medicare Expiry

Do you have a Healthcare or Concession / Pension card? *

YesNo

Health Care Card or Pension Card number *

HCC / Pension Expiry *

County of birth/ethnicity

Preferred language

Do you need an interpreter? *

Yes No

Is there a family member/support person you would like us to speak to? *

Yes No

Name of family member/support person

Contact number

Do you have a doctor?

Yes No

What is their name/practice?

Were there any other services previously involved? *Youth Mental Health Team, CAMHS, Bendigo Health Mental Health team, CASA, Anglicare, Haven, Youth Justice ect.

Are there any other services currently involved? *Youth Mental Health Team, CAMHS, Bendigo Health Mental Health team, CASA, Anglicare, Haven, Youth Justice ect.

Emergency contact

It is important that we have a trusted adult listed as an emergency contact.

We will only contact this person if we have concerns for your safety and wellbeing.

First name *

Last name *

Phone number *

Relationship to you *

I consent to headspace contacting my emergency contact *

YesNo

If we do not have consent to contact the person you have listed, we may need to speak with emergency services if we cannot contact you and have concerns for your wellbeing.

.

What is your reason for contacting headspace Bendigo?

Please specify

Please tick box if you DO NOT want a call to talk about other programs offered at headspace Bendigo

Tell us more here

Please tell us what you would like to gain by attending headspace?

Upload any relevant supporting documents - Shared support plan, relevant assessments, mental health care plan ect.

Browse

Your privacy is important to us. This information will be kept confidential and used only to give you the best care possible.

https://www.bchs.com.au/about/policies/privacy-policy

I have read and I understand this privacy information *

YesNo