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

This form is for referring yourself (or a young person you are supporting) to headspace Collingwood, headspace Frankston or headspace Rosebud. These centres are managed by YSAS, one of Australia’s largest alcohol and other drug support services for young people aged 12-25.

Unfortunately we are unable to process referrals to other headspace centres – if you live in another area, you can find your closest headspace centre here: https://headspace.org.au/headspace-centres/.

Referring yourself?

Hey – well done!  It’s a big step to link in to support! We aim to get back to people within 5 working days. If you want some more info about headspace (or to access some online support tools) you can check out https://headspace.org.au/ while you wait!

Referring someone else?

If you are a family member/friend/worker/support person referring a young person, please note that headspace is a voluntary service – young people are able to choose if they want to link in with us. 

We always recommend discussing the referral with the young person and gaining their consent.  

If you are referring from an agency/organisation, please attach any relevant documentation/reports – this helps us when planning support options. 

About the form

Please complete as much as you can, as this information helps to inform what support we can offer you! 

There are some questions (marked with an asterisk) that you are required to answer to submit the form. 

Please note – we are not a crisis service. 
If you or someone you know 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)

What do you need support with?

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!
Mental Health:
Physical Health:
AOD (Alcohol and Other Drugs):
Education/Employment:
Other issues:
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 us to get back to you personally, please leave your name and contact number or email below (optional)

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