Highly Skilled Australian Psychologists & Counselling Professionals

Client Intake Form

Client Intake Form

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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 - NEVER

    1 Applied to me to some of the time - SOMETIME

    2 Applied to me to a considerable degree, or a good part of time - OFTEN

    3 Applied to me very much, or most of the time - ALMOST ALWAYS

  • 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

    Normal0 - 40 - 30 - 7
    Mild5 - 64 - 58 - 9
    Moderate7 - 106 - 710 -12
    Severe11 -138 - 913 - 16
    Extremely Severe14+10+17+

K10 Form

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  • For all questions, please select the appropriate response. In the past 4 weeks:
  • Explanatory Notes

    What is the K10 and how is it scored?

    The K10 is widely recommended as a simple measure of psychological distress and as a measure of outcomes following treatment for common mental health disorders. The K10 is in the public domain and is promoted on the Clinical Research Unit for Anxiety and Depression website (www.crufad.org) as a self report measure to identify need for treatment.

    Scoring instructions

    Each item is scored from one ‘none of the time’ to five ‘all of the time’. Scores of the 10 items are then summed, yielding a minimum score of 10 and a maximum score of 50. Low scores indicate low levels of psychological distress and high scores indicate high levels of psychological distress.

    Interpretation of scores

    The maximum score is 50 indicating severe distress, the minimum score is 10 indicating no distress. The 2001 Victorian Population Health Survey adopted a set of cut-off scores that may be used as a guide for screening for psychological distress. These are outlined below:

    K10 Score: Likelihood of having a mental disorder (psychological distress)

    10 - 19 Likely to be well

    20 - 24 Likely to have a mild disorder

    25 - 29 Likely to have a moderate disorder

    30 - 50 Likely to have a severe disorder

    Questions 3 and 6 are not asked if the preceding question was ‘none of the time’ in which case questions 3 and 6 would automatically receive a score of one.

    For further information on the K10 please refer to www.crufad.org or Andrews, G Slade, T.

    Interpreting score on the Kessler Psychological Distress Scale (K10). Australia and New Zealand Journal of Public Health: 2001; 25:6: 494-497.

Client - Therapist Feedback Form

  • This form allows you an opportunity to provide feedback after your sessions have finished. This will help your Therapists professional development as well as helping to improve the services offered to others. You DO NOT need to identify yourself.

    Place a mark in the box which most closely corresponds to how you feel about each statement.
  • About the Working Relationship With Your Therapist

  • About the Results of Working With Your Therapist

  • Overall Satisfaction

  • Administrative Considerations

  • Other Comments

    Please use the space below for any other comments you would like to bring to your counsellor’s attention. If you include your name in this section, it will be treated as CONFIDENTIAL. If you need more space, please continue on the back or add another page.

Session Rating Scale (SRS V.3.0) Form

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  • Please rate today’s session by placing a mark on the line nearest to the description that best fits your experience.

Consent to Release Information Form

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Referral Form

  • Filling out the request form Companies requesting services from LIFESKILLS AUSTRALIA must complete Parts A, B, C (all service types). The authorised representative must sign the ‘Referral to Lifeskills Australia – Psychology & Counselling’ and any written report. Sending the request Email (preferable method): info@lifeskillsaustralia.com.au
  • Part B: Employee/Potential Employee to be Assessed
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  • Max. file size: 50 MB.
  • Other Employee/Potential Employee to be Assessed
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  • Max. file size: 50 MB.
  • Part C Company Details
  • Authorisation (Company authorised representative)
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