Self-referral form

Emotional Wellbeing Program Self Referral

Self-Referral for our FREE Emotional Wellbeing Program Our Emotional Wellbeing Program is designed to offer FREE brief (3 sessions), evidence-based psychological interventions for people 18+ years living in the South West of WA, who hold a current Health Care Card OR are in financial hardship. You will have the choice of phone/video calls or face to face with one of our Mental Health Professionals. If you are experiencing any of the below, this service may be of help to you: • Feeling anxious • Low mood, sadness • Feeling hopeless or worthless • Finding it difficult to do everyday things because of how you feel • Worrying more than usual • Not being able to relax because of your thoughts or feelings • Avoiding doing things because they make you feel anxious Interventions focus on the here and now, offering support, education and skill development to help improve your mental wellbeing and daily functioning. This might include learning self-help techniques such as anxiety and mood management, relaxation, problem solving and mindfulness. If you think this program is for you, please complete the self-referral form below. Once the form below is submitted you will be contacted by us within 7 working days to discuss your well-being plan further. If you have any questions, reach out to us through the email swprograms@oseca.com.au. PLEASE NOTE THAT THIS IS NOT A CRISIS SERVICE If you are in crisis or in need of urgent assistance, please call Lifeline on 131114, or present to your closest Hospital Emergency Dept. If an emergency call 000 for Police, Ambulance or Fire Brigade.

"*" indicates required fields

Full Name

Address

AREA – 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 Birth

Are you of Aboriginal or Torres Strait Islander origin?*

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

Please choose your employment type*

Full-time

Part-time

Casual

Not applicable

Other

Are you employed?*

Yes

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

The following self-assessment will show you how affected by stress/anxiety you are. It looks at the last 4 weeks.

In the last 4 weeks, about how often did you feel tired out for no good reason?*

About how often do you feel nervous?*

About how often did you feel so nervous that nothing could calm you down?*

About how often did you feel hopeless?*

About how often did you feel restless or fidgety?*

About how often did you feel so restless that you could not sit still?*

About how often did you feel depressed?*

About how often did you feel that everything was an effort?*

About how often did you feel so sad that nothing could cheer you up?*

About how often did you feel worthless?*

In 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

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

By submitting this form you agree to the following statement

This organisation will work closely with your GP and other agencies to coordinate the best support for you your family, your carer and/or your support person. Your consent is required for Oseca and its programs and services to do this. Please read the information below and complete the client section of the form overleave. You may withdraw consent from any services provided by Oseca at any time. Your informed consent for sharing information will be sought and respected in all situations except when: •We are obliged by law to disclose your information regardless of consent or otherwise; •There is risk of safety to you or another person •Without information being shared, it is anticipated a child, young person or adult will be at risk of serious harm, abuse or neglect, or pose a risk to their own or public health or safety. Protecting your privacy Oseca is committed to providing you with the highest level of service and confidentiality, and this includes protecting your privacy. Oseca is bound by the Australian Privacy Principles contained in Schedule 1 of the Privacy Act 1988 and supported by the Privacy Amendment (Enhancing Privacy Protection) Act 2012, which outline the principles concerning the protection of your personal information. Collection, exchange and disclosure of information Personal information may be shared between Oseca and external organisations with your agreement after discussion, otherwise all information we keep about you is confidential. Program evaluation Oseca at times, is required to record information that does not identify you and report this information back to its funding bodies. This information will not contain your name or date of birth. Health organisations often undertake a review of client records to ensure that information is being recorded accurately and effectively. This process is usually referred to as an audit. Similarly, an audit does not involve collecting personal information such as name and date of birth. Information management All information collected about you is confidential and will be stored securely in a locked or password protected place. Your personal information will remain confidential and secure except: • where it is requested by a court; • there is a risk of safety to you or another person; • if disclosure is required by state or commonwealth law or if prior approval has been obtained. You may withdraw from any services provided by Oseca at any time. Thank you for engaging with Oseca's Emotional Wellbeing Program. This program is funded by WAPHA and is free of charge. To inform and make continual improvements WAPHA may send you a survey so you may share your experience with them.

Emotional Wellbeing Program Self Referral

The following self-assessment will show you how affected by stress/anxiety you are. It looks at the last 4 weeks.

By submitting this form you agree to the following statement

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