headspace Youth Early Psychosis Program
Referral Form

Please return completed form to:

Medical Objects: HEADSPACE SOUTHPORT

Questions: Contact us on 0423 614 781	

Program Details
The headspace Youth Early Psychosis Program provides specialised assessment and intervention for young people aged 12-25 who are at risk of experiencing a first episode of psychosis. Upon referral to the program, the young person will be assessed by our multi-disciplinary team. Feedback on the outcome of the assessment will be provided to the referrer.

Referring General Practitioner/Health Professional
Name: <UsrName>	Profession: <Referrer's Profession>	
Practice Name: <Practice>	Practice Phone: <UsrPhone>	
Address: <UsrAddress>	Email: <PracEmail>	

Date: <TodaysDate>

Patient Details
RE: <PtFullName>
DOB: <PtDoB>
Gender: <PtSex>	Home phone: <PtPhoneH>
Mobile phone: <PtPhoneMob>	
Address: <PtAddress>	Email: <PtEmail>	
Language preferred: <Language preferred>	Parent/Caregiver consent: <Has parent/caregiver given consent (pt under 16)>	

Does the young person have any current mental health diagnoses: <Does pt have any current Mental Health diagnoses>
If yes, please specify: <If yes, specify Mental Health diagnoses>

Does the young person have any physical health condition/diagnoses? <Does pt have physical health condition/diagnoses>
If yes, please specify: <If yes, specify physical health condition/diagnoses>

General Patient Information
<Please select from the list below the details that are relevant to the patient>

30% decline in functioning (moderate difficulty in social, occupational or school functioning - not functioning at an age appropriate level)	<30% decline in functioning (not age appropriate)>	
1st degree relative with psychosis	<1st degree relative with psychosis>	
Attending school/university/TAFE	<Attending school/university/TAFE>	
Employed	<Employed>	
Substance misuse	<Substance misuse>	
Suicidal ideation	<Suicidal ideation>	
Suicidal plan	<Suicidal plan>	
Suicidal intent	<Suicidal intent>	
Deliberate Self Harm	<Deliberate Self Harm>	
Violence or aggression towards others	<Violence or aggression towards others>	

Symptomology
Hallucinations or perceptual disturbances: auditory/visual/tactile e.g. Hearing voices or sounds (banging, clapping, scratching), seeing people or shadows, feeling crawling sensation on skin	<Hallucinations or perceptual disturbances>	
Delusional beliefs (ideas of reference, paranoia, suspiciousness, grandiosity)	<Delusional beliefs>	
Blunted affect	<Blunted affect>	
Odd or unusual behaviour	<Odd or unusual behaviour>	
Decrease in motivation/energy/lack of interest in activities	<Decrease in motivation/energy/lack of interest>	
Social withdrawal/isolation	<Social withdrawal/isolation>	
Cognitive decline (concentration, memory, planning)	<Cognitive decline (concentration, memory, planning)>	
Change in appetite and/or change in sleep pattern/quality/quantity	<Change in appetite/sleep pattern/quality/quantity>	

Current Medications
<CurrentRx>

Privacy Statement: All information provided is protected under our privacy and confidentiality guidelines