Self Referral Please enable JavaScript in your browser to complete this form.Thank you for filling in this questionnaire, it will give Dr Peter some background information which is helpful to have before your appointment. PERSONAL INFORMATIONFirst Name *Surnmane *Address 1 *Address 2SuburbPost Code *Date of Birth *Email *Day time phoneMobile phone *DOCTOR DETAILName of GPGP PracticeREFERRALWhat do you feel are your main concerns? *How long doyou feel this has been a problem for you? *If you have had contact with mental health professionals or counsellors in the past please give details.If you have any physical health concerns please identify them here. *If you are on any prescribed medication from your doctor please detail them here.If you have any family members who have had mental health issues please detail.If you are in a relationship please indicate how happy it is for you? *Very happyMainly happyOccasionally happyRarely happyNot in a relationshipHow stable do you feel your relationship is? *Very stableOccasional wobblesUnstableMight break upNot in a relationshipOn average over 7 days, how many standard drinks of alcohol would you consume (one standard drink equals 350mls of 4% beer or 100mls of table wine)? *0 - 3 standard drinks5 - 10 standard drinks10 - 15 standard drinksmore than 15 standard drinksDo you ever use illicit drugs or substances?YesNoWhich one best applies to you *unemployedpart time or casual employmentself employedstudentfull time employmentSELF ASSESSMENTOver the last four weeks:About how often did you feel tired out for no good reason? *None of the timeA little of the timeSome of the timeMost of the timeAll of the timeAbout how often did you feel nervous? *None of the timeA little of the timeSome of the timeMost of the timeAll of the timeAbout how often did you feel so nervous that nothing could calm you down? *None of the timeA little of the timeSome of the timeMost of the timeAll of the timeAbout how often did you feel hopeless? *None of the timeA little of the timeSome of the timeMost of the timeAll of the timeAbout how often did you feel restless or fidgety? *None of the timeA little of the timeSome of the timeMost of the timeAll of the timeAbout how often did you feel so restless you could not sit still? *None of the timeA little of the timeSome of the timeMost of the timeAll of the timeAbout how often did you feel depressed? *None of the timeA little of the timeSome of the timeMost of the timeAll of the timeAbout how often did you feel that everything was an effort? *None of the timeA little of the timeSome of the timeMost of the timeAll of the timeAbout how often did you feel so sad that nothing could cheer you up? *None of the timeA little of the timeSome of the timeMost of the timeAll of the timeAbout how often did you feel worthless? *None of the timeA little of the timeSome of the timeMost of the timeAll of the timeIn general, do you have difficulty making and keeping friends? *yesnoWould you normally describe yourself as a loner? *yesnoIn general, do you trust other people? *yesnoDo you normally loose your temper easily? *yesnoAre you normally an impulsive sort of person? *yesnoAre you normally a worrier? *yesnoIn general, do you depend on others a lot? *yesnoIn general, are you a perfectionist? *yesnoPersonal Wellbeing IndexPlease answer the following questions on a scale of 0 to 10, where 0 means no satisfaction at all, and 10 means fully satisfied.1. "Thinking about your own life and personal circumstances, how satisfied are you with your life as a whole?" *0123456789102. "How satisfied are you with what you are achieving in life?"0123456789103. "How satisfied are you with feeling part of the community?" *0123456789104. "How satisfied are you with your standard of living?" *0123456789105. "How satisfied are you with your personal relationships?" *0123456789106. "How satisfied are you with your future security?" *0123456789107. "How satisfied are you with your health?" *0123456789108. "How satisfied are you with how safe you feel?" *0123456789109. "How satisfied are you with your spirituality or religion?" *012345678910OUTCOMESWhat do you hope to gain by seeing Dr Peter?Do you want your GP to get a letter from Dr Peter outlining the consultation with you? *yesnoDr Peter makes an audio recording of all his sessions, would you like to have a copy? *yesnoPricingUnless there is a prior arrangment, the initial mental health assessment is up to 90 minutes and the cost is $485.00 (inc GST). Follow up sessions last up to 50 minutes and cost $285.00 (inc gst). *agreedisagreeTerms and ConditionsTo maintain the confidentiality of sessions with Dr Peter *AgreeDisagreeSessions are recorded, do you: *AgreeDisagreePayment is by EFTPOS or credit card at the end of the session *AgreeDisagreeIn the event of non-payment all costs of debt recovery are born by you. *AgreeDisagreeHow did you hear about Dr Peter? *From my GPFrom a friendFrom his websiteGoogle searchOtherIf other, please specify:Are there any matters you would like to talk with Dr Peter prior to your first appoinment? *yesnoPhoneSubmit
