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 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: Profession	
Practice Name: Practice.Name	Practice Phone: Practice.Phone	
Address: Practice.Address	Email: Practice email	

Date: Miscellaneous.Date

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: Language preferred	Parent/Caregiver consent: Consent	

Does the young person have any current mental health diagnoses: MH diagnoses
If yes, please specify: Specify MH diagnoses

Does the young person have any physical health condition/diagnoses: Physical health
If yes, please specify: Specify health

General Patient Information
Patient Information

30% decline in functioning (moderate difficulty in social, occupational or school functioning - not functioning at any age appropriate level)	Functioning decline	
1st degree relative with psychosis	1st degree relative	
Attending school/university/TAFE	School/uni/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/aggression	

Symptom ology
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	
Delusional beliefs (ideas of reference, paranoia, suspiciousness, grandiosity)	Delusional beliefs	
Blunted affect	Blunted affect	
Odd or unusual behaviour	Odd behaviour	
Decrease in motivation/energy/lack of interest in activities	Decrease motivation	
Social withdrawal/isolation	Social withdrawal	
Cognitive decline (concentration, memory, planning)	Cognitive decline	
Change in appetite and/or change in sleep pattern/quality/quantity	Appetite/sleep	

Current Medications
Clinical Details.Medications - Current Regular

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