headspace Youth Early Psychosis Program
Referral Form

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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 or 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: <<Miscellaneous:Current User>>	Profession: <<Referrer's Profession>>	
Practice Name: <<Practice:Name>>	Practice Phone: <<Practice:Phone>>	
Address: <<Practice:Address>>	Email: <<Practice:E-mail>>	

Date: <<Miscellaneous:Date (short)>>

Patient Details
RE: <<Patient Demographics:Full Name>>
DOB: <<Patient Demographics:DOB>>
Gender: <<Patient Demographics:Gender>>	Home phone: <<Patient Demographics:Phone (Home)>>
Mobile phone: <<Patient Demographics:Phone (Mobile)>>	
Address: <<Patient Demographics:Full Address>>	Email: <<Patient Demographics:E-mail>>	
Language preferred: <<Patient Demographics: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
<<General Patient Information>>

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
<<Clinical Details:Medication List>>

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