Flipside Referral Form

IMPORTANT INFORMATION ABOUT YOUR REFERRAL- PLEASE READ

Flipside supports young people from 10-25 years and works with young people, families and community to strengthen wellbeing and mental health. Flipside provides early intervention support for those experiencing mild mental health and wellbeing difficulties through psychosocial support, case management and general counselling. Flipside is located at the Roxby Downs Health Service and works from Roxby Downs Area School.Waitlist- given the demand for Flipside services, there may be a waitlist at times. You will be advised by a staff member via phone call or letter. We request that you seek urgent help from your GP or local hospital should your situation change. We recommend a list of services including eheadspace and Beyond Blue.

Young Person Details

Full name *

Preferred name

Gender

Preferred Pronouns

Date of Birth *

Previous Client?

YesNo

Please provide your Cultural Background

Language spoken

Interpreter Required

YesNo

Address *

Street address *

City *

State *

Postcode *

This service is only available within South Australia. Check our services page for specific locations. Or contact Head to Health directly on 1800 595 212 or visit website www.headtohealth.gov.au for alternative services in their area.

Above address is my postal address

YesNo

Postal Address

Street address

City

State

Postcode

This service is only available within South Australia. Check our services page for specific locations. Or contact Head to Health directly on 1800 595 212 or visit website www.headtohealth.gov.au for alternative services in their area.

Is it okay for us to send headspace branded documents to this address?

YesNo

Phone *

Is it okay for us to contact you via SMS?

YesNo

Email Address

Is it okay for us to send information via email?

YesNo

Client’s Key Contact Person (in case of emergency)

Name *

Phone *

Relationship to young person *

Is the young person subject to any guardianship or custody orders?

YesNo

Details

Referrer Details

Is this a self referral?

YesNo

Name of Referrer (if NOT self-referral) *

Phone *

Relationship to Young Person *

Referrer Email *

Referrer Organization

GP Details

Does the young person have an existing GP?

YesNo

Name of GP

Surgery Name

Phone

Does the young person have a Mental Health Treatment Plan?

YesNo

Referral details

What are the current issues? (please include information about the duration, age of onset and pre-existing diagnoses) Please attach further information/relevant assessments, reports etc.

What has been the impact of these issues? (e.g. relationships, school, work, home etc.)

Risk Factors (self / referrer to complete)

Please check the appropriate boxes below

Suicidal thoughts *

YesNo

Present in last 3 months

YesNo

Past issue

YesNo

Suicidal behaviour *

YesNo

Present in last 3 months

YesNo

Past issue

YesNo

Deliberate Self harm *

YesNo

Present in last 3 months

YesNo

Past issue

YesNo

Harm to others *

YesNo

Present in last 3 months

YesNo

Past issue

YesNo

Hospital presentation (for mental health concern) *

YesNo

Present in last 3 months

YesNo

Past issue

YesNo

If selected “yes” to suicidal behaviour or hospital presentation in last 3 months, please contact headspace Whyalla on 86414330 to discuss referral

Young Person Supports & Consent

Does young person consent to referral?

YesNo

If under 16 do carers consent to referral?

YesNo

Does the young person receive support from other agencies?

YesNo

Does the young person consent to sharing information with these services?

YesNo

Does the young person consent to sharing information with referrer?

YesNo

Does the young person consent to sharing information with other services to determine the most appropriate support?

YesNo

Agencies

Caregiver 1 Name

Caregiver 1 Signature

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Caregiver 2 Name

Caregiver 2 Signature

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Young Person Signature

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Date

Other (please specify) *

REFERRAL OUTCOME (office use only)

Eligible for Flipside services?

YesNo

Rationale

Appointment Date

Appointment Time