Australia's Best Psychologists & Counselling Experts

Client Intake Form

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DAS 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 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 ALWAYS

K10 Form

  • 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.

Outcome Rating Scale (ORS) Form

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  • 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.

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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  • Other Employee/Potential Employee to be Assessed
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  • Part C Company Details
  • Authorisation (Company authorised representative)
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