Urgent Help
IS THIS AN EMERGENCY?
Are you or others in danger? Do you need an ambulance or the police? 24 HOURS
Lifeline
24 hour phone line for crisis support and suicide prevention. 24 HOURS
13YARN
24 hour crisis phone line support for Aboriginal and Torres Strait Islander people. 24 HOURS

Young people, loved ones or workers can make referrals to YSAS run headspaces with this form

This form is for referring yourself (or a young person) to headspace Collingwood, Frankston or Rosebud. 

This information is collected so we can start the process of responding to your request for support, and it will help us to inform the next steps for the care you may need. We aim to get back to people within 5 working days. 

There are some questions that you are required to answer to submit the form – we have labelled these with an asterisk (*).

Please answer as many questions as you can!

Please note – we are not a crisis service. 
If you or someone you knows needs immediate support you can attend your local Urgent Care clinic or Emergency Department, or call:
Emergency – 000
Lifeline – 13 11 14
Beyond Blue – 1300 22 4636
Kids Helpline – 1800 55 1800

headspace Referral Form

DD slash MM slash YYYY
Gender
Does the young person identify as:
Which site would you like a referral to?(Required)
If you are contacting us on behalf of a young person, are they aware of this referral?(Required)
Please note that we are a voluntary service - young people are able to choose whether or not they want to link in with us!
Who is making this referral? (Tick "self" if you're referring yourself!)(Required)
Preferred Contact Method(Required)
Do you (or the referred young person) need access to an interpreter?(Required)
Select any/all issues that are relevant to you/referred young person. If it isn't listed, please enter in the "other" box at the end!
Select any/all issues that are relevant to you/referred young person. If it isn't listed, please enter in the "other" box at the end!
Select any/all issues that are relevant to you/referred young person. If it isn't listed, please enter in the "other" box at the end!
Select any/all issues that are relevant to you/referred young person. If it isn't listed, please enter in the "other" box at the end!
Select any/all issues that are relevant to you/referred young person. If it isn't listed, please enter in the "other" box at the end!
Would you (or the referred young person) like to involve a family member or support person when connecting with us?(Required)
Max. file size: 50 MB.
By submitting this form, I am consenting to the headspace centre I have selected to securely holding this information, and making contact with myself and/or the young person directly.(Required)
YSAS (including YSAS managed headspace programs) needs to collect personal information from you so we can give you quality health care, and we need your permission to collect and keep this information. By law, we must ensure your information stays private. Our Privacy Policy conforms to the Privacy Act 1998 (Cth) and other government laws and regulations.

If you would like the us to get back to you personally, please leave your name and contact number or email below (optional)

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