Client Intake Forms

A Few of Our EAP Partners

View our forms below for you to fill out. If you have any questions, please don’t hesitate to contact us.

Client Intake Form

Client Intake Form

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Are you Aboriginal or Torres Strait Islander Origin?(Required)
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Mental Health Care plan
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Are you a FIFO Worker?(Required)
EAP (Employment Assistant Program)(Required)
How did you hear about us?
Referred by
Privacy Policy(Required)


DASS (with total)

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Please read each statement and circle a number 0, 1, 2 or 3 which indicates 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.

The rating scale is as follows:
0 - Did not apply to me at all
1 - Applied to me to some degree, or some of the time
2 - Applied to me to a considerable degree, or a good part of time
3 - Applied to me very much, or most of the time

1. I found myself getting upset by quite trivial things
2. I was aware of dryness of my mouth
3. I couldn't seem to experience any positive feeling at all
4. I experienced breathing difficulty (eg, excessively rapid breathing, breathlessness in the absence of physical exertion)
5. I just couldn't seem to get going
6. I tended to over-react to situations
7. I had a feeling of shakiness (eg, legs going to give way)
8. I found it difficult to relax
9. I found myself in situations that made me so anxious I was most relieved when they ended
10. I felt that I had nothing to look forward to
11. I found myself getting upset rather easily
12. I felt that I was using a lot of nervous energy
13. I felt sad and depressed
14. I found myself getting impatient when I was delayed in any way (eg, lifts, traffic lights, being kept waiting)
15. I had a feeling of faintness
16. I felt that I had lost interest in just about everything
17. I felt I wasn't worth much as a person
18. I felt that I was rather touchy
19. I perspired noticeably (eg, hands sweaty) in the absence of high temperatures or physical exertion
20. I felt scared without any good reason
21. I felt that life wasn't worthwhile
22. I found it hard to wind down
23. I had difficulty in swallowing
24. I couldn't seem to get any enjoyment out of the things I did
25. I was aware of the action of my heart in the absence of physical exertion (eg, sense of heart rate increase, heart missing a beat)
26. I felt down-hearted and blue
27. I found that I was very irritable
28. I felt I was close to panic
29. I found it hard to calm down after something upset me
30. I feared that I would be "thrown" by some trivial but unfamiliar task
31. I was unable to become enthusiastic about anything
32. I found it difficult to tolerate interruptions to what I was doing
33. I was in a state of nervous tension
34. I felt I was pretty worthless
35. I was intolerant of anything that kept me from getting on with what I was doing
36. I felt terrified
37. I could see nothing in the future to be hopeful about
38. I felt that life was meaningless
39. I found myself getting agitated
40. I was worried about situations in which I might panic and make a fool of myself
41. I experienced trembling (eg, in the hands)
42. I found it difficult to work up the initiative to do things
Total Depression Score
Total Anxiety Score
Total Stress Score

DASS Severity Ratings

The DASS is a quantitative measure of distress along the 3 axes of depression, anxiety1 and stress2. It is not a categorical measure of clinical diagnoses. Emotional syndromes like depression and anxiety are intrinsically dimensional - they vary along a continuum of severity (independent of the specific diagnosis). Hence the selection of a single cut-off score to represent clinical severity is necessarily arbitrary. A scale such as the DASS can lead to a useful assessment of disturbance, for example individuals who may fall short of a clinical cut-off for a specific diagnosis can be correctly recognised as experiencing considerable symptoms and as being at high risk of further problems.

However for clinical purposes it can be helpful to have ‘labels’ to characterise degree of severity relative to the population. Thus the following cut-off scores have been developed for defining mild/moderate/severe/ extremely severe scores for each DASS scale.

Note: the severity labels are used to describe the full range of scores in the population, so ‘mild’ for example means that the person is above the population mean but probably still way below the typical severity of someone seeking help (ie it does not mean a mild level of disorder.

The individual DASS scores do not define appropriate interventions. They should be used in conjunction with all clinical information available to you in determining appropriate treatment for any individual.

1. Symptoms of psychological arousal
2. The more cognitive, subjective symptoms of anxiety

Depression Anxiety Stress
Normal 0 - 4 0 - 3 0 - 7
Mild 5 - 6 4 - 5 8 - 9
Moderate 7 - 10 6 - 7 10 -12
Severe 11 -13 8 - 9 13 - 16
Extremely Severe 14+ 10+ 17+
Consent to Release Information Form

Consent to Release Information Form

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