Client Intake Form SalutationsMrMsMissMrsMxSurname*Given Name*Address*Suburb*Postcode*Birthdate* Date Format: DD slash MM slash YYYY Email* PH (Mobile)WorkHomeOccupation*Sex*MaleFemaleUndetermined / Intersex / UnspecifiedAre you of Aboriginal or Torres Strait Islander origin?*Yes, AboriginalYes, Torres Strait IslanderYes, both Aboriginal & Torres Strait IslanderNoGP Name*GP Number*NDIS #Medicare #Reference #Date Date Format: MM slash DD slash YYYY Pension CardExpiry Date Date Format: MM slash DD slash YYYY Health Care CardExpiry Date Date Format: MM slash DD slash YYYY Mental Health Care planYesNoDate of Plan Date Format: MM slash DD slash YYYY Next of Kin*Relationship*Phone Number*Are you a FIFO Worker?*YesNoEAP (EmploymentAssistantProgram)*YesNoIf Yes, Employers/Company NameSitePosition/title at this companyor, your partner's positionPartner's NameHow did you hear about us?Walk ByGoogleWebsiteFacebookOtherReferred by Friend Family Other* I agree to the Privacy Policy DAS Form Name*Date* Date Format: DD slash MM slash YYYY 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 degree, or some of the time - SOMETIMES 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 ALWAYSI found it hard to wind down*0123I was aware of dryness of my mouth*0123I couldn’t seem to experience any positive feeling at all*0123I experienced breathing difficulty (eg, excessively rapid breathing, breathlessness in the absence of physical exertion)*0123I found it difficult to work up the initiative to do things*0123I tended to over-react to situations*0123I experienced trembling (eg, in the hands)*0123I felt that I was using a lot of nervous energy*0123I was worried about situations in which I might panic and make a fool of myself*0123I felt that I had nothing to look forward to*0123I found myself getting agitated*0123I found it difficult to relax*0123I felt down-hearted and blue*0123I was intolerant of anything that kept me from getting on with what I was doing*0123I felt I was close to panic*0123I was unable to become enthusiastic about anything0123I felt I wasn’t worth much as a person*0123I felt that I was rather touchy*0123I was aware of the action of my heart in the absence of physicalexertion (eg, sense of heart rate increase, heart missing a beat)*0123I felt scared without any good reason*0123I felt that life was meaningless*0123 K10 Form Full Name*For all questions, please select the appropriate response. In the past 4 weeks:About how often did you feel tired out for no good reason?*None of the timeA little of the timeSome of the timeMost of the timeAll of the timeAbout how often did you feel nervous?*None of the timeA little of the timeSome of the timeMost of the timeAll of the timeAbout how often did you feel so nervous that nothing could calm you down?*None of the timeA little of the timeSome of the timeMost of the timeAll of the timeAbout how often did you feel hopeless?*None of the timeA little of the timeSome of the timeMost of the timeAll of the timeAbout how often did you feel restless or fidgety?*None of the timeA little of the timeSome of the timeMost of the timeAll of the timeAbout how often did you feel so restless you could not sit still?*None of the timeA little of the timeSome of the timeMost of the timeAll of the timeAbout how often did you feel depressed?*None of the timeA little of the timeSome of the timeMost of the timeAll of the timeAbout how often did you feel that everything was an effort?*None of the timeA little of the timeSome of the timeMost of the timeAll of the timeAbout how often did you feel so sad that nothing could cheer you up?*None of the timeA little of the timeSome of the timeMost of the timeAll of the timeAbout how often did you feel worthless?*None of the timeA little of the timeSome of the timeMost of the timeAll of the time 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. Outcome Rating Scale (ORS) Form First Name*Last Name*Email Address*Age*Gender*MaleFemaleSession #*Date* Date Format: DD slash MM slash YYYY Who is filling out this form? Please check one:*SelfOtherIf other, what is your relationship to this person?*Looking back over the last week, including today, help us understand how you have been feeling by rating how well you have been doing in the following areas of your life, where marks to the left represent low levels and marks to the right indicate high levels. If you are filling out this form for another person, please fill out according to how you think he or she is doing.Individually (Personal well-being)*12345678910Interpersonally (Family, close relationships)*12345678910Socially (Work, school, friendships)*12345678910Overall (General sense of well-being)*12345678910 Session Rating Scale (SRS V.3.0) Form Name First Last AgeID #GenderMaleFemaleSession #Date Date Format: DD slash MM slash YYYY Please rate today’s session by placing a mark on the line nearest to the description that best fits your experience.Relationship1 - I did not feel heard, understood, and respected.2345 - I felt heard, understood, and respected.Goals and Topics1 - We did not work on or talk about what I wanted to work on and talk about.2345 - We worked on and talked about what I wanted to work on and talk about.Approach or Method1 - The therapist’s approach is not a good fit for me.2345 - The therapist’s approach is a good fit for me.Overall1 - There was something missing in the session today.2345 - Overall, today’s session was right for me. Consent to Release Information Form I ,Date Date Format: DD slash MM slash YYYY Authorise Lifeskills Australia: Psychology & Counselling to release the following information:To (name and title of person(s) and/or organisation (s) to which disclosure is to be made):For the following purposes* I agree to the Privacy Policy 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 A: Type of Service-- Select --Mental Health fitness for work assessment (for advice on how to safely manage a mental health issue).Workplace behaviour coachingGeneral wellbeing checkExtended or ongoing counsellingMediation and/or Conflict ResolutionCrisis Intervention (phone or face to face counselling)OtherPart B: Employee/Potential Employee to be Assessed Last Name*Given Name*Date of Birth* Date Format: DD slash MM slash YYYY Division (if applicable)Gender*MaleFemaleEmployee NumberWork AddressWork PhoneWork Email Home AddressHome PhoneHome Email Title of PositionMobile PhoneConfirmation SMSYesNoHas the employee been notified?YesNoIs Lifeskills Australia to contact employee directly?YesNoIf No, (Specify)Has the employee signed a consent to release information form?YesNoIf yes please attachIf a current employee?YesNoIs employee currently on duty?YesNoOther Employee/Potential Employee to be Assessed Last NameGiven NameDate of Birth Date Format: DD slash MM slash YYYY Division (if applicable)GenderMaleFemaleEmployee NumberWork AddressWork PhoneWork Email Home AddressHome PhoneTitle of PositionMobile PhoneConfirmation SMSYesNoHas the employee been notified?YesNoIs Lifeskills Australia to contact employee directly?YesNoIf No, (Specify)Has the employee signed a consent to release information form?YesNoIf yes please attachIf a current employee?YesNoIs employee currently on duty?YesNoPart C Company Details Company NameCompany Contact (information / results / report)Contact person’s position titleAddressPhone / MobileEmail Authorisation (Company authorised representative) Name of Authorising PersonPosition of Authorising PersonDate Date Format: DD slash MM slash YYYY Email Phone