Intake Form
Email to: headspaceliverpool@benevolent.org.au or
Fax referral to: 02 8568 7932
We strongly recommend anyone referring a Young Person to also call and speak to an intake
worker on 1800 026 517. Our opening hours are 8.30am to 5.00pm, Monday to Friday.
Referrals are considered the week after we receive them. We’ll be in touch after that to offer an
appointment or to discuss who might be in a better position to support you / the Young Person.
We are not an emergency service. If you / the Young Person needs immediate assistance, please
call the mental health care line (1800 011 511) or go to the nearest hospital emergency department.
Date:
Who’s referring? Self Service provider Family/friend Walk-in
Does the YP know about this referral? Yes
If not, the referral cannot be
Is the YP between 12 and 25 years of age? Yes accepted. Please call and
we can support you to find
If under 16 years, are the parents/carers aware? Yes other options.
Name
Date of Birth
Gender
Address
Who with? At home with family Living alone
Staying with friends Homeless
Refuge supported accommodation
YP Phone Number
Email (optional)
Name of parent/guardian
(optional)
Is YP at school, TAFE, university or working? Yes No
Where? Year / Level?
What cultural background does the YP identify as?
Does YP need an interpreter? Yes No
If ‘Yes’, what language?
Office Use: Entered in Profile Entered in Allocation Intake worker:
Is YP from a refugee background? Yes No
Is YP of Aboriginal or Torres Strait Islander background? Yes No
1. What’s lead to referring to headspace? What are the current concerns?
2. Is the YP at risk of harming themselves or others? Are there any identifiable risk factors? (e.g.
thoughts of suicide, self-harm, risk-taking behaviours, harming others)
3. Anything else happening that might be affecting the YP? (e.g. family issues, exam stress, issues
with friends or relationships)
4. Anything from the past that might be affecting the YP now?
5. Any previous mental health support / treatment, counselling, medication or diagnoses?
6. What does the YP feel would be useful about coming to headspace? How motivated are they to
come?
7. Any other information that may be relevant? (e.g. family history of mental health issues, court
involvement, intellectual disability, physical disability)
Are any of these issues for the YP at the moment?
Physical health Sexual health Body image Alcohol or drugs
Legal issues
Referrer details (if appropriate)
Name Position / Organisation
Best contact number Email
Fax Address
Who is the best person to contact about this referral? YP
Parent / Guardian
Referrer
Does YP have a GP? Yes No
GP Name Medical Centre / Practice
Is there a current Mental Health Treatment Plan? Yes No
Any other workers/services involved?
Name Position / Organisation / Contact number
(Office Use Only)
ALLOCATION FOLLOW-UP
