Service Provider Referral Form - Headspace

Service Provider Referral FormPresenting Issues:Please summarise: please include relevant information onlyHome and Environment: (e.g. Who do they reside with? What are they relationships like athome?)____________________________________________________________________________________________________________________________________________________________________________________Education and Employment: (e.g. Are they are school? Are they working?)____________________________________________________________________________________________________________________________________________________________________________________Daily Activities: (e.g. Do they have friends they hang out with? What do they like doing?)____________________________________________________________________________________________________________________________________________________________________________________Drugs and Alcohol: (e.g. Do they drink, smoke, or use drugs? Do they use them regularly? Dothey help calm them down?)____________________________________________________________________________________________________________________________________________________________________________________Relationships and Sexuality: (e.g. Are they in, or ever been in relationship? Are they sexuallyactive?)____________________________________________________________________________________________________________________________________________________________________________________Conduct Difficulties and Risk Taking: (Do they self harm? Do they often feel out of control?)____________________________________________________________________________________________________________________________________________________________________________________Anxiety and Eating: (e.g. Do they experience excessive worry? Are they anxious in certainsituations? Do they worry about their body and weight?)____________________________________________________________________________________________________________________________________________________________________________________Depression and Suicide: (Risk Assessment if available including suicidal and homicidalfactors)____________________________________________________________________________________________________________________________________________________________________________________Psychosis / Mania: ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Referrer’s Signature:______________________________________ Date:_________________________The referrer agrees that all information submitted in this referral is an accurate reflection of the client’s supportneeds, is correct with no information withheld and is necessary for the organisation to fulfil its duty of care to clients,staff and other partner agencies.