Session by Session Questionnaire

The following questionnaire must be completed by the individual requesting the Session by Session appointment.

This form will be reviewed on the day of your appointment. In an Emergency, please call 000 or go to your local hospital Emergency Department, or in a crisis, you can call Lifeline 13 11 14.

headspace Hawthorn and headspace Malvern are both run by the lead agency - Access Health & Community. This form may be reviewed by the intake team at both sites. You will be asked which site you prefer to access. All your information is private and confidential and all information you submit on this form, is stored on a secure server.

Please ensure you read 'Your Rights and Responsibilities' document and the Privacy Statement before proceeding with this form.

Please tick this box to ensure you understand the information above *

What is your preferred centre? *

Today's date: *

Have you had an appointment at headspace Hawthorn or headspace Malvern before? *

YesNo

Personal Details

Your given name: *

Your surname (last name): *

Preferred name:

Date of birth: *

Gender *

Pronouns:

Contact number: *

Suburb: *

Contact Information

Street address: *

Suburb: *

Contact number: *

Email address: *

Additional Information

Are you Aboriginal or Torres Strait Islander? *

No AboriginalTorres Strait IslanderAboriginal and Torres Strait Islander

Country of birth: *

Cultural background:

Preferred language: *

Do you need an interpreter? *

YesNo

If yes, which language? *

Emergency Contact:

Emergency contact's name: *

Relationship to emergency contact: *

Emergency contact's phone number: *

Your counselling appointment

What are the main concerns that you would like to discuss? *

What have you already tried to do to help - what worked/didn't work? *

What would you like to get out of today's session? *

Are you worried about harm to yourself or others? *

Is there anything else we should know so you can safely access headspace? *

Once you submit this form, you consent to headspace Hawthorn and/or headspace Malvern contacting you. The Intake team will make every effort to contact you within 2 business days. Please call us if needed.

headspace Hawthorn 03 9006 6500
headspace Malvern 03 9006 6550