top of page
MensPsych
Psychology Services
PH: 08 7523 4597 FAX: 08 8490 5560
Home
Our Practice
Our Team
What's up?
FAQs
Contact
Blog
More
Use tab to navigate through the menu items.
Name
Email
Phone Number
Age (in years)
Do any of the following apply to you?
*
Mental Health Care Plan / Referral
NDIS Psychology Funding
DVA Funding
None of the above
What is your relationship status
Do you have any children? Please provide info including their living/care arrangements
Please describe your main reason(s) for seeking Psychological Therapy
In terms of your reason for seeking Psychological Therapy, how long have these issues been a challenge for you?
Have you seen a Psychologist / Other Therapist in the past?
*
No
Yes, related to my current challenges/issues
Yes, but related to other challenges/issues
Have you been diagnosed with a mental health (e.g., Depression) or developmental disorder (e.g., ADHD/Autism) in the past? Please describe
Do you take any prescription medications for mental health problems?
*
Yes
No
Unsure
During the past week have you felt:
Depressed
Anxious
Irritable
Stressed
Fatigued
Unmotivated
Are you quick to react with anger/frustration?
*
Yes - Always
Yes - Sometimes
No
Are you an impulsive person? (e.g., drinking, eating, gambling, shopping)
*
Yes
No
Unsure
Select any of the following that apply to you
I have trouble completely finishing a project/activity once the challenging bits are completed
I have difficulty getting things in order/organised to complete a task
I often fidget - move your hands and feet - or have difficulty sitting still
Select any of the following that apply to you
I find connecting with people and building/maintaining friendships difficult
I feel uncomfortable making eye contact with people when talking to them
I enjoy consistent routine and find it stressful if the routine changes or is interrupted
I have highly specific and strong interests that I spend a lot of time on
How often do you have more than four alcoholic drinks in a day?
Daily
Weekly
Monthly
Rarely
Never
Have you every felt guilty about your drinking, or that you need to cut down?
*
Yes
No
Unsure
Has anyone commented on your drinking, or suggested that you cut down?
*
Yes
No
Unsure
How often do you use illegal drugs or prescription medication for non-medical reasons?
*
Daily
Weekly
Monthly
Rarely
Never
Have you every felt guilty about using illegal drugs or prescription medication?
*
Yes
No
Unsure
In the past year, have you had an issue with gambling such as betting when you didn't have sufficient funds, or feeling guilty about betting?
*
Yes
No
Unsure
Is there a current Apprehended Violence Order (AVO) in place that restricts any aspect of your behaviour?
*
Yes
No
Unsure
Are you currently engaged in legal proceedings for any matter, including child custody or visitation issues?
*
Yes
No
Unsure
I consent to this information being reviewed by therapists and administration staff of MensPsych Psychology Services. I acknowledge that providing this information does not guarantee that I will be offered an appointment with a Psychologist. I understand that I am providing this information to assist MensPsych to determine whether their psychologists might be able to assist me with my mental health, and that the decision to accept me as a client (or not) resides with the treating psychologist.
Submit
bottom of page
