"*" indicates required fields Full NameAddressAREA – Living in the SW region of WA. (Program only available for people living, studying, or working in Bunbury and surrounds, Collie, Harvey, Warren Blackwood region, Margaret River/Augusta region, Busselton and surrounding areas.* Bunbury Busselton Collie Harvey Warren Blackwood region Margaret River/Augusta region Other Email* Phone*Date of Birth* MM slash DD slash YYYY Gender*Emergency Contact Name & Phone Number* (Due to Emotional Well-being Program being a mental health support service, we require an emergency contact. This contact will not be communicated with unless we have any safety concerns)Country of BirthAre you of Aboriginal or Torres Strait Islander origin?* No Yes, Aboriginal Yes, Torres Strait Islander Yes, both - Aboriginal & Torres Strait Islander Prefer not to say Main language spoken at home*Relationship Status* Single Married Divorced Widowed Prefer not to say Other Are you employed?* Yes No Please choose your employment type* Full-time Part-time Casual Not applicable Other English proficiency* Very Well Well Not Well Not at all Your GP name*Practice Name*What are your biggest challenges right now?*Choose a topic you would like to focus on with your mental health practitioner* Helping you cope with anxiety Feeling sad Feeling stressed Difficulty communicating with others Do you have a network of friends or family that you can turn to for support?* Yes No The following self-assessment will show you how affected by stress/anxiety you are. It looks at the last 4 weeksIn the last 4 weeks, about how often did you feel tired out for no good reason?*All the timeMost of the timeSome of the timeA little of the timeNone of the timeAbout how often do you feel nervous?*All the timeMost of the timeSome of the timeA little of the timeNone of the timeAbout how often did you feel so nervous that nothing could calm you down?*All the timeMost of the timeSome of the timeA little of the timeNone of the timeAbout how often did you feel hopeless?*All the timeMost of the timeSome of the timeA little of the timeNone of the timeAbout how often did you feel restless or fidgety?*All the timeMost of the timeSome of the timeA little of the timeNone of the timeAbout how often did you feel so restless that you could not sit still?*All the timeMost of the timeSome of the timeA little of the timeNone of the timeAbout how often did you feel depressed?*All the timeMost of the timeSome of the timeA little of the timeNone of the timeAbout how often did you feel that everything was an effort?*All the timeMost of the timeSome of the timeA little of the timeNone of the timeAbout how often did you feel so sad that nothing could cheer you up?*All the timeMost of the timeSome of the timeA little of the timeNone of the timeAbout how often did you feel worthless?*All the timeMost of the timeSome of the timeA little of the timeNone of the timeIn the past four weeks, how many days were you totally unable to work, study or manage your day to day activities because of these feelings? (0-30 days)*Aside from those days, in the past four weeks, how many days were you ABLE to work, study or manage your day-to-day activities but had to cut down on what you did because of these feelings? (0-30 days)*In the past four weeks, how many times have you seen a doctor or any other health professional about these feelings? (0-30 days)*In the past four weeks, how often have physical health problems been the main cause of these feelings?* All of the time Most of the time Some of the time A little of the time None of the time In the last four weeks have you had any thoughts of self-harm?* Yes No What mode of service would you prefer?Face-to-face only available in Busselton, Bunbury, Bridgetown, Manjimup, Margaret River and Harvey) Phone Online/Video Link (Similar to Zoom) What time and day would be best to call you back to discuss the best service for you?*Availability: Monday to Thursday 9:00 am to 3:30 pm Δ
