Client Intake Form Client Intake Form Salutations Mr Ms Miss Mrs Mx Surname* Given Name* Address* Suburb* Postcode* Birthdate* DD slash MM slash YYYY Email* PH (Mobile) Work Home Occupation* Sex* Male Female Undetermined / Intersex / Unspecified Are you of Aboriginal or Torres Strait Islander origin?* Yes, Aboriginal Yes, Torres Strait Islander Yes, both Aboriginal & Torres Strait Islander No GP Name* GP Number* NDIS # Medicare # Reference # Date MM slash DD slash YYYY Pension Card Expiry Date MM slash DD slash YYYY Health Care Card Expiry Date MM slash DD slash YYYY Mental Health Care plan Yes No Date of Plan MM slash DD slash YYYY Next of Kin* Relationship* Phone Number* Are you a FIFO Worker?* Yes No EAP (EmploymentAssistantProgram)* Yes No If Yes, Employers/Company Name Site Position/title at this company or, your partner's position Partner's Name How did you hear about us? Walk By Google Website Facebook Other Referred by Friend Family Other * I agree to the Privacy Policy DAS Form Name* Date* 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* 0 1 2 3 I was aware of dryness of my mouth* 0 1 2 3 I couldn’t seem to experience any positive feeling at all* 0 1 2 3 I experienced breathing difficulty (eg, excessively rapid breathing, breathlessness in the absence of physical exertion)* 0 1 2 3 I found it difficult to work up the initiative to do things* 0 1 2 3 I tended to over-react to situations* 0 1 2 3 I experienced trembling (eg, in the hands)* 0 1 2 3 I felt that I was using a lot of nervous energy* 0 1 2 3 I was worried about situations in which I might panic and make a fool of myself* 0 1 2 3 I felt that I had nothing to look forward to* 0 1 2 3 I found myself getting agitated* 0 1 2 3 I found it difficult to relax* 0 1 2 3 I felt down-hearted and blue* 0 1 2 3 I was intolerant of anything that kept me from getting on with what I was doing* 0 1 2 3 I felt I was close to panic* 0 1 2 3 I was unable to become enthusiastic about anything 0 1 2 3 I felt I wasn’t worth much as a person* 0 1 2 3 I felt that I was rather touchy* 0 1 2 3 I was aware of the action of my heart in the absence of physicalexertion (eg, sense of heart rate increase, heart missing a beat)* 0 1 2 3 I felt scared without any good reason* 0 1 2 3 I felt that life was meaningless* 0 1 2 3 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 time A little of the time Some of the time Most of the time All of the time About how often did you feel nervous?* None of the time A little of the time Some of the time Most of the time All of the time About how often did you feel so nervous that nothing could calm you down?* None of the time A little of the time Some of the time Most of the time All of the time About how often did you feel hopeless?* None of the time A little of the time Some of the time Most of the time All of the time About how often did you feel restless or fidgety?* None of the time A little of the time Some of the time Most of the time All of the time About how often did you feel so restless you could not sit still?* None of the time A little of the time Some of the time Most of the time All of the time About how often did you feel depressed?* None of the time A little of the time Some of the time Most of the time All of the time About how often did you feel that everything was an effort?* None of the time A little of the time Some of the time Most of the time All of the time About how often did you feel so sad that nothing could cheer you up?* None of the time A little of the time Some of the time Most of the time All of the time About how often did you feel worthless?* None of the time A little of the time Some of the time Most of the time All 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* Male Female Session #* Date* DD slash MM slash YYYY Who is filling out this form? Please check one:* Self Other If 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)* 1 2 3 4 5 6 7 8 9 10 Interpersonally (Family, close relationships)* 1 2 3 4 5 6 7 8 9 10 Socially (Work, school, friendships)* 1 2 3 4 5 6 7 8 9 10 Overall (General sense of well-being)* 1 2 3 4 5 6 7 8 9 10 Session Rating Scale (SRS V.3.0) Form Name First Last Age ID # Gender Male Female Session # Date 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.Relationship 1 - I did not feel heard, understood, and respected. 2 3 4 5 - I felt heard, understood, and respected. Goals and Topics 1 - We did not work on or talk about what I wanted to work on and talk about. 2 3 4 5 - We worked on and talked about what I wanted to work on and talk about. Approach or Method 1 - The therapist’s approach is not a good fit for me. 2 3 4 5 - The therapist’s approach is a good fit for me. Overall 1 - There was something missing in the session today. 2 3 4 5 - Overall, today’s session was right for me. Consent to Release Information Form I , Date 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)Other Part B: Employee/Potential Employee to be Assessed Last Name* Given Name* Date of Birth* DD slash MM slash YYYY Division (if applicable) Gender* Male Female Employee Number Work Address Work Phone Work Email Home Address Home Phone Home Email Title of Position Mobile Phone Confirmation SMS Yes No Has the employee been notified? Yes No Is Lifeskills Australia to contact employee directly? Yes No If No, (Specify) Has the employee signed a consent to release information form? Yes No If yes please attachMax. file size: 2 GB.If a current employee? Yes No Is employee currently on duty? Yes No Other Employee/Potential Employee to be Assessed Last Name Given Name Date of Birth DD slash MM slash YYYY Division (if applicable) Gender Male Female Employee Number Work Address Work Phone Work Email Home Address Home Phone Title of Position Mobile Phone Confirmation SMS Yes No Has the employee been notified? Yes No Is Lifeskills Australia to contact employee directly? Yes No If No, (Specify) Has the employee signed a consent to release information form? Yes No If yes please attachMax. file size: 2 GB.If a current employee? Yes No Is employee currently on duty? Yes No Part C Company Details Company Name Company Contact (information / results / report) Contact person’s position title Address Phone / Mobile Email Authorisation (Company authorised representative) Name of Authorising Person Position of Authorising Person Date DD slash MM slash YYYY Email Phone
