Personal Details
Please fill this information out to the best of your knowledge.  Completing this questionnaire will help us tailor you the best assistance.
It is ok if you do not know everything, please fill what you know.

This questionnaire takes approximately 20 minutes to complete.  Please do not spend too much time on any question, just put the answer that is right for you.

Please review our Privacy page and Terms and Conditions to find out how your information is used and what to expect (www.mindzone.com.au).
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Your Details (our Client)
First Name: *
Middle Name:
Last Name: *
Are you known by other names?
Prefer to be called: *
 e.g. Dr Smith, or John
Date of Birth and Age:
e.g. 01/12/1969 (47yo)
Your contact and family details:
Mobile Phone:
Home Phone:
Other Phone:
Please indicate what type; e.g. Work: 07 3333 4444
Address:
Please include your address
Family Details:
Please tell us a little about your family members, include children, parents, partner.  Their ages, whether or not they are living with you, etc.
Next of kin (emergency contact/ guardian) details:
Relationship to your next of kin:
e.g. Cousin, Mother, etc.
Next of kin First Name:
Next of kin Last Name:
Next of kin Contact:
Please include at least one contact; e.g. mobile number
Your Education and Employment details
Your Education
Your education details
Your Employment
Your employment details.  If unemployed, please indicate how long for.
Current Military Service
Please include if you are in current military service
Clear selection
Military Rank
If you are currently in the military service, what is your rank?
Unit
If you are currently in the military service, what is your unit?
Your health and Referral Details:
Date of Referral
If referred by VVCS, please indicate who referred you? Please include the name of your Doctor.
e.g. Dr Smith
How did you find out about us?
e.g. Newspaper
Medication Details:
Please tell us what medication you are taking, dose, are you taking it as directed? What is your experience? (e.g. side effects, effectiveness… etc.)
Please list your 3 main concerns
Please tell us your expectation from therapy:
Symptom Checklist
Place a number beside the symptom you are concerned about at present.
0 = none of the time; 1 = sometimes; 2 = a lot of the time;  3 = most of the time
Sleep disturbance
none of the time
most of the time
Clear selection
Appetite disturbance
none of the time
most of the time
Clear selection
Weight loss / gain
Significant changes in your weight
none of the time
most of the time
Clear selection
Headaches
none of the time
most of the time
Clear selection
Excessive self-criticism
none of the time
most of the time
Clear selection
Brooding about the past
(ruminating)
none of the time
most of the time
Clear selection
Feelings of depression or excessive sadness
none of the time
most of the time
Clear selection
Excessive or unrealistic fear
none of the time
most of the time
Clear selection
Social withdrawal or isolation
none of the time
most of the time
Clear selection
Difficulty solving problems
none of the time
most of the time
Clear selection
Memory concern
none of the time
most of the time
Clear selection
Loss of energy
none of the time
most of the time
Clear selection
Anxiety
(shakes, sweating, breathlessness, palpitations)
none of the time
most of the time
Clear selection
Difficulty thinking
none of the time
most of the time
Clear selection
Feelings of worthlessness
none of the time
most of the time
Clear selection
Excessive guilt
none of the time
most of the time
Clear selection
Angry thoughts
none of the time
most of the time
Clear selection
Decreased pleasure or enjoyment
none of the time
most of the time
Clear selection
Loss of motivation
none of the time
most of the time
Clear selection
Impaired ability to make decisions
none of the time
most of the time
Clear selection
Difficulty setting goals
none of the time
most of the time
Clear selection
Feeling ‘slowed down’
none of the time
most of the time
Clear selection
Excessive crying
none of the time
most of the time
Clear selection
Agitation
(jittery, cant sit still)
none of the time
most of the time
Clear selection
Difficulty concentrating
none of the time
most of the time
Clear selection
Feelings of helplessness
none of the time
most of the time
Clear selection
Decreased self-confidence
none of the time
most of the time
Clear selection
Feelings of hopelessness
none of the time
most of the time
Clear selection
Apathy and indifference
none of the time
most of the time
Clear selection
Decreased productivity
none of the time
most of the time
Clear selection
Anything else you wish to tell us?
e.g. your goals, hobbies, what works for you, your strengths, etc.
I have read, understand, and agree to the Privacy statement and Terms and Conditions *
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