Referral Guidelines 
About headspace Bega (Eden, Cooma and Narooma) 
 
headspace Bega is a free, youth-friendly and confidential service for young people aged 12 – 25 years.  Lead by Grand Pacific Health, headspace Bega offers the following supports and services including:  

•	Mental Health Support 
•	Drug and Alcohol Support 
•	Education and Employment Support 
•	Physical Health and Sexual Health 

headspace Bega is a voluntary service. The young person needs to be aware of and consent to the referral and be willing to meet with a member from the headspace Bega team. As such, referral to our service cannot proceed unless consent to refer is obtained. 

The headspace Bega hub also provides outpost services to Eden, Cooma and Narooma 3 days per week on Tuesday, Wednesday and Thursday. 

PLEASE NOTE: 
headspace Bega is not an acute mental health/crisis service. If you have any immediate concerns regarding the safety/wellbeing of a young person, please call: Mental Health Line 1800 011 511; Lifeline on 13 11 14; or Kids Helpline on 1800 55 1800. In an emergency, contact 000 immediately.  

HOW TO REFER: 
Self-Referral 
Young people are encouraged to make contact with the headspace Bega service directly. Young people in Eden, Cooma and Narooma can access our centralised intake via the Bega hub or drop in and see a Youth Care Coordinator in their town for assistance to link in with our intake worker over the phone.  

By phone/email 
Young people can call 1800 959 844 within office hours or email info@headspacebega.org.au and a worker will contact the young person to complete a referral. 

Drop in 
Young people can call into headspace Bega between 9am and 5pm, Monday- Friday or at one of our outreach locations between 9am and 5pm Tuesday-Thursday. Staff will endeavour to see the young person the same day or will assist them with a referral and an appointment will be made as soon as possible.

Professional Referral- Service Providers 
GP’s, Allied Health Professionals, community-based agencies and educational institutions can all refer young people to headspace Bega using the Service Providers Referral Form. General Practitioners should include a mental health care plan (if appropriate) for the young person and attach this to the headspace Bega referral form. 

Family Referral 
Families, carers or friends can refer a young person to headspace Bega. Once receipt of referral has been confirmed, a worker will contact the young person to make an appointment. Families, parents or carers who have a young person engaged with headspace Bega can also access our centre to discuss service provision

For more information regarding headspace Bega and outpost locations please contact us directly or visit our website https://headspace.org.au/headspace-centres/bega/

How to submit this form:
In Person: Rooftop Carpark, Sapphire Market Place. 1/83 Upper St, Bega 
Fax: (02) 6494 8855
Mail: PO Box 513 Bega NSW, 2580

CONFIDENTIAL 
	
headspace Bega General Referral Form
 
If you are unsure about making the referral please contact headspace for consultation.

Date of referral: ____/_____/___

Young Person (Client) Details

Name________________________________________Age__________ DOB: ____/_____/___ 
Sex:____Male      Female      Gender Diverse      Intersex      Indeterminate      Other 
Address:_________________________________________________________________________ 
Suburb:____________________________________________________________
Residing with Family?   Y / N 
Ph:_______________________________________Fax:____________________________________
Mob Ph:_____________________________________Email:_______________________________
Education:___________________________________________________Year:_________________

Employed (circle):	 Fulltime 			Part-time 	 			Unemployed

Other Contact Details

Next of Kin / Other contact person:____________________________________________________
Relationship: ____________________Ph: ___________________Mob:______________________ 
This person can be contacted in case of emergency		Y / N

Referrer Details

Name_____________________________Organisation/Service: _______________________________

Job Title: ___________________________________________________________________________

Ph: ________________________________________Fax:____________________________________
			
Mob Ph: ___________________________________ Email: ___________________________________

Is the client aware of the referral and wanting treatment?	  	Yes  	 No 

Has the client got their own GP?  			  		Yes	 No	Unsure

If yes, has a Mental Health Care Plan been created? 	  	Yes	 No	Unsure

Young Person Specifics 

Presenting Issues:
1. _______________________________________________________________________________
2._______________________________________________________________________________
3._______________________________________________________________________________
What supports does the young person identity as needing? 
__________________________________________________________________________________________________________________________________________________________________________
What supports do you feel that young person would benefit from to support their mental and emotional wellbeing?
__________________________________________________________________________________________________________________________________________________________________________

What skills and strengths does the young person bring? (eg family supports, social network, others)
__________________________________________________________________________________________________________________________________________________________________________

History of Presenting Problem:
__________________________________________________________________________________________________________________________________________________________________________

Duration of current issues (circle):
		Days		   Weeks		Months			Years

Relevant background information:
__________________________________________________________________________________________________________________________________________________________________________
Previous Mental Health Treatment (by whom/ dates)
_____________________________________________________________________________________

Other Services Involved-
Current:______________________________________________________________________________
Previous:_____________________________________________________________________________

Risk (please tick and detail risk is indicated):
•	Self-Harm _____________________________________________________________________
•	Suicidality______________________________________________________________________
•	Risk to others___________________________________________________________________
•	Other Risk Behaviours ____________________________________________________________

What service are you requesting from headspace (tick all that apply)?

•	Mental Health Clinician 
•	Peer work
•	Drug/Alcohol  
•	Dietetics 	
•	Employment/Education

Other Comments:
__________________________________________________________________________________________________________________________________________________________________________
Please fax the completed form marked attention to “Intake” on 02 6494 8855