The Mental Wellness Assistance Society of NS Application For Mental Care
Contact Information
Please enter your first name: *
Please enter your last name *
Please enter your email *
Please enter your phone number *
Please enter your province *
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Please enter your postal code *
Please enter your health card number *
Please enter your emergency contact name *
Please enter your emergency contact number *
Please enter your date of birth *
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Please enter emergency contact relationship *
Please enter the full name of your family doctor *
Medical History
1) Have you ever been diagnosed with a mental illness such as Depression, Anxiety, Bipolar Disorder? If yes, what was the diagnosis and when were you diagnosed? *
2)If you were diagnosed with the mental illnesses mentioned above, what was the diagnosis, and when were you diagnosed? If you were not diagnosed, skip the question.
3) If you were diagnosed with the mental illnesses mentioned above, what treatment have you sought? If you were not diagnosed, skip the question.
4)Do you have a chronic health condition such as diabetes, COPD, thyroid? *
5) What medications do you take? Include the name, dose, and for what? (eg pain, arthritis, depression etc) *
Personal History
6)How many cigarettes do you smoke in a day? *
7)How many alcohol drinks do you have weekly? *
8) How often do you smoke marijuana? *
9) How many caffeinated drinks do you have daily? Include coffee, tea, and cola *
10) Do you have difficulties with sleep? If yes, please describe the difficulty *
11) Are you married or living common law? *
12) If you answered "yes" to question 11, please indicate the words or phrases that best describe your relationship. Otherwise, skip the question.
13) If you answered "yes" to question 11, how long have you been together? Otherwise skip this question.
14) If you answered "yes" to question 11, are you divorced or separated? Otherwise, skip this question.
Clear selection
15) If you are divorced or separated, please indicate the words or phrases that best describe your relationship with your ex?
16) Do you have children? *
17) If you do have children, how many?
18) If you do have children, how old are they?
19) If separated or divorced, please describe child living arrangements *
Employment History
20) What is your place of employment? *
21) What is your work position?
22) What does your partner do for a living? *
23) What is your household income? *
24) How many people are living in your household including you and your spouse (if applicable)? *
25) Do you pay or receive child support? *
26) Do you have health insurance? If yes, how much coverage for Mental Health help /year? *
Family History
27) Did either of your parents have a history of mental health problems, including addictions and gambling? If yes, which parent and what was the problem? *
28) Do any of your siblings have a history of mental health problems including addictions and gambling? If yes, what was/is the issue? *
29) Is there anything about your childhood, adolescence, or adulthood that you think I should know? *
30) What are the main problems that you having right now? *
Do you have a therapist you would like to use? If so, please give their name and phone number. *
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