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| * Please enter your name: | | |
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| * Contact number (this will be used to facilitate feedback of your responses): | | |
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| Education / Work / Career |
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| What capacity are you currently working? |
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| What subject/discipline are you studying? | | |
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| What is your highest level of formal education? |
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| What best describes your current employment situation? |
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| How many people live in your home? | | |
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| What best describes your relationship status? |
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| For how long has this been your relationship status? | | |
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| Do you have kids? If yes, what ages? | | |
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| Do you have brothers and sisters? If yes, what ages? | | |
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| Do any family members have mental health challenges? (i.e. professionally diagnosed) |
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| Emotional and Mental Health |
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| Please read each statement and indicate how much the statement applied to you over the past week. There are no right or wrong answers. Do not spend too much time on any statement.
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| What medications do you take that your GP prescribes? (for both physical and mental health purposes) | | |
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| Have you taken any medications that have had negative side effects? (Please explain if 'yes') | | |
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| Have you had any major traumas (both physical and mental)? | | |
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| If applicable, please describe any recent hospitalisations (including length of stay): | | |
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| Have you seen a psychologist and/or psychiatrist in the past? If so, for what purpose? | | |
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| Have you seen a psychologist under a mental health plan in the last 12 months? |
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| What other allied health professionals do you usually visit for treatment? | | |
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| When was your last visit to the GP? | | |
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| Do you experience moderate to severe pain? |
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| Does this affect your day to day functioning and prevents you from doing normal activities? |
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| Do you have any health conditions? (e.g. blood pressure, thyroid, recent illnesses, etc.)? | | |
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| What other medical conditions are you currently experiencing that have not already been mentioned? | | |
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| How many hours of sleep on average do you have per night? (If applicable, what dream content is present)? | | |
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| What vitamins/minerals do you take to improve your health? | | |
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| Do you drink more than 2 cups of coffee or caffeine drinks per day? |
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| Do you drink more than 2-4 standard drinks per day of alcohol? |
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| Have you used illicit drugs in the past? |
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| Do you feel your physical health is? |
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| Do you eat 2-3 meals per day? |
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| Do you drink at least 1 litre of fluid per day? |
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| How many times a week do you exercise for more than 15 minutes? | | |
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| Does your weight increase or decrease when you are stressed? If so, by what range of kg? | | |
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| Have you had any serious accidents or incidents in your life where you were injured or felt helpless/severe pain/fear? (Please briefly describe) | | |
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| Miscellaneous Questions and Satisfaction Questions |
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| Do you have spiritual beliefs that are important to consider? If yes, what faith/religion do you value or wish to be included in your counselling? | | |
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| How would you rate your financial situation? |
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| How satisfied are you with the following:
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| * Please rank the areas of life in order of most interested in changing / developing? (1= Most Interested; 5=Least Interested) |
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| Work / Career |
| | | Personal relationships |
| | | Physical Health |
| | | Personal Growth |
| | | Spirituality |
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| In your own words, what appears to be the problem / challenge / issue with the area you selected as of most interest to change and/or develop? | | |
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| How long has it been this way? | | |
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| What other areas are troubling you? | | |
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| What gives you reason to be happy, to laugh? (If you did know or had to guess, what would it be?) | | |
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| * Assuming the following statement "Nothing is your fault, but everything is your responsibility"... this being the case, how would you rate your commitment for change? |
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| How would you rate the length of this survey? |
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Thank you for completing this Emotional Health Survey.
Your responses will be reviewed by a registered psychologist and you will be contacted on the number provided in order to debrief and give feedback on any questions you may have.
Have a nice day.
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Further Resources:
• Lifeline Telephone Counselling, Phone: 13 11 14.
• Online Resources: http://www.psychology.org.au/community/links/mental_health/
• Better Access to Mental Health Care Initiative (Medicare Items): http://www.psychology.org.au/medicare/better_access/
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