Therapeutic Services - Online Intake

Welcome to our Therapeutic Services intake process. 

To provide you with the best possible support, we ask for some basic information about yourself and your needs. This intake form can take up to 15 minutes to complete - Please answer as many questions as you can.  

This form can be used to complete an intake for our: 

• Drug and Alcohol,

• Family Violence, 

• General Mental Health Counselling  or

• Financial Counselling services

If you are interested in registering for a service that is not here (eg. PLC services, Medical Services) or if you would prefer to complete this intake form over the phone, please call us on:  (03) 9865 6700 , between 9:30am - 4:30pm, Monday to Friday.  

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Data Collection and Privacy

We collect your personal and health information to provide you with safe and effective care. Your information is kept private and secure in line with legal and ethical requirements. For more details, you will receive a copy of our Client Rights and Responsibilities document at the end of this form.

I understand and agree to the collection of my personal and health information for the purpose of receiving support from Thorne Harbour Health *

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A Little bit about you

Preferred First Name

Last Name

Date of Birth

Your Contact Details

Phone Number

Email address

Home Address

Street addressStreet address line 2

City

StatePlease selectACTNSWNTQLDSATASVICWA

Postcode

CountryPlease selectAfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiComorosCongo (Brazzaville)CongoCosta RicaCote d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast Timor (Timor Timur)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint VincentSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbia and MontenegroSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamYemenZambiaZimbabwe

What is your preferred contact method?

PhoneEmail

Do we have consent to:

Call you Leave a voicemail Send you an SMS

Have you previously been a client of Therapetuic Services (Counselling, Alcohol and Other Drugs or Family violence) at Thorne Harbour Health? *

Yes - I have accessed Counselling, Family Violence or AOD services at Thone Harbour HealthNo - I am new to Thorne Harbour Health I am unsure

Can you tell us about your Gender, Sex and Sexuality

What is your gender?

AgenderFemale/WomanGender QueerMale/ManNon-BinaryPrefer not to sayQuestioningProvide own gender (below)

What are your pronouns?

She/HerHe/HimThey/ThemThey/HeThey/She He/She/TheyNo Pronouns (Name Only)Providing own pronouns (below)

If providing own gender, please specify:

If providing own pronouns, please specify:

What is your sexuality?

AsexualGayHeterosexualLesbian Multi-Gender Attracted (Bi-sexual, Pansexual, Omnisexual, etc.)Prefer not to answerQueerQuestioningProvide own identity (below)

If providing own identity, please specify

What is your sex assigned at birth?

MaleFemalePrefer not to answer

Do you identify as transgender?

YesNo Unsure Prefer not to answer

Do you have an intersex variation?

YesNo UnsurePrefer not to answer

Can you tell us about your cultural background

What is your cultural background/ethnicity?

Do you identify with being Aboriginal and/or Torres Strait Islander? *

Aboriginal Torres Strait IslanderBoth Aboriginal and Torres Strait IslanderNeither Aboriginal nor Torres Strait IslanderPrefer not to answer

What language/s do you speak at home?

Do you require an interpreter to engage in services?

YesNo

If yes, which language/s?

A little bit about your Blood Borne Virus Status

What is your HIV Status

NegativePositiveUnsure

What is your HEP C Status?

NegativePositiveUnsure

If positive, what year were you diagnosed?

If Positive, what year were you diagnosed?

What's most important for you right now? (Pick one to start with): *

Alcohol and Other Drug SupportGeneral Mental Health Counselling SupportFamily Violence SupportFinancial Counselling Support

Alcohol and Other Drug (AOD) Program Intake

Have you recently exited (or are you about to exit) Detox/Rehab, a mental health or wellness facility, or a forensic institution

Yes No

A little bit about your substance use:

What Substance/s are you seeking assistance for:

In the past four weeks (28 days) have you used any of the following substances?

YesNo

Alcohol

YesNo

Cannabis

YesNo

Methamphetamine

YesNo

Other amphetamine type stimulants (e.g. MDMA /ecstasy, diet pills etc)

YesNo

Prescribed sedatives or sleeping pills (e.g. benzodiazepines, xanax, valium, serapax, rohypnol, stilnox etc)

YesNo

Non-prescribed benzodiazepines

YesNo

Prescribed Opioids (e.g. methadone/buprenorphine)

YesNo

Non-prescribed Opioids (e.g. heroin, codeine, methadone, oxycodone, morphine, fentanyl etc)

YesNo

Cocaine

YesNo

Inhalants

YesNo

Hallucinogens

YesNo

Tobacco

YesNo

GHB

YesNo

Other substances (e.g. steroids caffeine/energy drinks, new and emerging drugs etc)

Have you injected drugs in the past four weeks?

YesNo

If yes, how many days did you inject drugs in the last 4 weeks (28 days)

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A little bit about alcohol:

Have you used Alcohol in the last year

YesNo (If No, please skip to the next section)

How often do you have a drink containing alcohol?

Never Monthly or less 2-4 times a month 2-3 times a week 4 or more times a week

How many drinks containing alcohol do you have on a typical day when you are drinking?

1 or 2 3 or 4 5 or 6 7 to 9 10 or more

 

Never Less than monthly Monthly Weekly Daily or almost daily

How often do you have six or more drinks on one occasion?

Never Less than monthly Monthly Weekly Daily or almost daily

How often during the last year have you found that you were not able to stop drinking once you had started?

Never Less than monthly Monthly Weekly Daily or almost daily

How often during the last year have you failed to do what was expected of you because of drinking?

Never Less than monthly Monthly Weekly Daily or almost daily

How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session?

Never Less than monthly Monthly Weekly Daily or almost daily

How often during the last year have you had a feeling of guilt or remorse after drinking?

Never Less than monthly Monthly Weekly Daily or almost daily

How often during the last year have you been unable to remember what happened the night before because of your drinking?

Never Less than monthly Monthly Weekly Daily or almost daily

 

No Yes, but not in the last year Yes, during the last year

Have you or someone else been injured because of your drinking?

No Yes, but not in the last year Yes, during the last year

Has a relative, friend, doctor, or other health care worker been concerned about your drinking or suggested you cut down?

No Yes, but not in the last year Yes, during the last year

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A little bit about the use of other drugs

Have you used drugs (other than alcohol) in the last year?

YesNo (please skip to the next section)

A little bit about drug use

Never Once a month or less often4 times a week or more often2-3 times a week2-4 times a month

How often do you use drugs other than alcohol?

Never Once a month or less often4 times a week or more often2-3 times a week2-4 times a month

Do you use more than one type of drug on the same occasion?

Never Once a month or less often4 times a week or more often2-3 times a week2-4 times a month

 

0 1-2 3-4 5-6 7 or more

How many times do you take drugs on a typical day when you use drugs?

0 1-2 3-4 5-6 7 or more

 

Never Less often than once a monthEvery monthEvery weekDaily or almost every day

How often are you influenced heavily by drugs?

Never Less often than once a monthEvery monthEvery weekDaily or almost every day

Over the past year, have you felt that your longing for drugs was so strong that you could not resist it?

Never Less often than once a monthEvery monthEvery weekDaily or almost every day

How often over the past year have you taken drugs and then neglected to do something you should have done?

Never Less often than once a monthEvery monthEvery weekDaily or almost every day

Over the past year, have you found that you have not been able to stop taking drugs once you started?

Never Less often than once a monthEvery monthEvery weekDaily or almost every day

How often over the past year have you needed to take a drug the morning after heavy drug use the day before?

Never Less often than once a monthEvery monthEvery weekDaily or almost every day

How often over the past year have you had guilt feelings or a bad conscience because you used drugs?

Never Less often than once a monthEvery monthEvery weekDaily or almost every day

 

No Yes, but not over the past year Yes, over the past year

Have you or anyone else been hurt (mentally or physically) because you used drugs?

No Yes, but not over the past year Yes, over the past year

Has a relative or a friend, a doctor or a nurse, or anyone else, been worried about your drug use or said to you that you should stop using drugs?

No Yes, but not over the past year Yes, over the past year

One Final Question Set

During the past 30 days, how often did you feel:

None of the timeA littlle of the timeSome of the timeMost of the timeAll of the time

tired for no good reason?

None of the timeA littlle of the timeSome of the timeMost of the timeAll of the time

nervous?

None of the timeA littlle of the timeSome of the timeMost of the timeAll of the time

so nervous that nothing could calm you down?

None of the timeA littlle of the timeSome of the timeMost of the timeAll of the time

hopeless?

None of the timeA littlle of the timeSome of the timeMost of the timeAll of the time

restless or fidgety?

None of the timeA littlle of the timeSome of the timeMost of the timeAll of the time

so restless that you could not sit still?

None of the timeA littlle of the timeSome of the timeMost of the timeAll of the time

depressed?

None of the timeA littlle of the timeSome of the timeMost of the timeAll of the time

so depressed that nothing could cheer you up?

None of the timeA littlle of the timeSome of the timeMost of the timeAll of the time

that everything was an effort?

None of the timeA littlle of the timeSome of the timeMost of the timeAll of the time

worthless?

None of the timeA littlle of the timeSome of the timeMost of the timeAll of the time

Is there anything else you would like to tell us, or you think it is important we know?

General Counselling Program Intake

What made you reach out today:

During the past 30 days, how often did you feel:

None of the timeA littlle of the timeSome of the timeMost of the timeAll of the time

tired for no good reason?

None of the timeA littlle of the timeSome of the timeMost of the timeAll of the time

nervous?

None of the timeA littlle of the timeSome of the timeMost of the timeAll of the time

so nervous that nothing could calm you down?

None of the timeA littlle of the timeSome of the timeMost of the timeAll of the time

hopeless?

None of the timeA littlle of the timeSome of the timeMost of the timeAll of the time

restless or fidgety?

None of the timeA littlle of the timeSome of the timeMost of the timeAll of the time

so restless that you could not sit still?

None of the timeA littlle of the timeSome of the timeMost of the timeAll of the time

depressed?

None of the timeA littlle of the timeSome of the timeMost of the timeAll of the time

so depressed that nothing could cheer you up?

None of the timeA littlle of the timeSome of the timeMost of the timeAll of the time

that everything was an effort?

None of the timeA littlle of the timeSome of the timeMost of the timeAll of the time

worthless?

None of the timeA littlle of the timeSome of the timeMost of the timeAll of the time

Is there anything else you would like to tell us, or you think it is important we know?

Are you seeking

Support because you have or are experiencing violenceBehaviour Change support

Do you have any current/past orders/notices?

No/NoneIntervention order Court order Family Violence Safety Notice (FVSN)Other:

If Other, Please Specify:

What are the conditions (incl. expiry dates, court, case number if known)

Who is named on the order as the Affected Family Member (first name and last name)?

What is their relationship to you?

Are you mandated to attend a Men’s Behaviour Change Program?

YesNo Unsure

Do you have any charges, court dates or other legal matters that it would be helpful for us to know about?

Are there any children in your life?

YesNo

Can you tell us their names (first name, last name) and age

What is your relationship to the children?

What made you reach out today?

Have you recently separated or ended a relationship?

11. Have you recently completed a Family Violence assessment?

YesNo Unsure

A little bit about your situation

When did the family violence occur? (is it current, recent, or are you seeking assistance for a past incident)

When was the most recent incident?

Are you worried about your personal safety right now?

Are you unsafe to stay in your home right now due to Family Violence?

YesNo

If yes, can you provide some more information?

Who has been hurting you? ParentSibblingRomantic PartnerFormer PartnerHousemateOther

If Other, Please Specify

What type of violence have you been experiencing (please tick all that apply)

verbal abusephysical abusestalkingcontrolling youemotional abuse psychological abusesexual abuse

Have you recently completed a Family Violence assessment? *

YesNoUnsure

Are you currently linked in with any other FV service? (if so, please list them below)

What made you reach out today?

During the past 30 days, how often did you feel:

None of the timeA littlle of the timeSome of the timeMost of the timeAll of the time

tired for no good reason?

None of the timeA littlle of the timeSome of the timeMost of the timeAll of the time

nervous?

None of the timeA littlle of the timeSome of the timeMost of the timeAll of the time

so nervous that nothing could calm you down?

None of the timeA littlle of the timeSome of the timeMost of the timeAll of the time

hopeless?

None of the timeA littlle of the timeSome of the timeMost of the timeAll of the time

restless or fidgety?

None of the timeA littlle of the timeSome of the timeMost of the timeAll of the time

so restless that you could not sit still?

None of the timeA littlle of the timeSome of the timeMost of the timeAll of the time

depressed?

None of the timeA littlle of the timeSome of the timeMost of the timeAll of the time

so depressed that nothing could cheer you up?

None of the timeA littlle of the timeSome of the timeMost of the timeAll of the time

that everything was an effort?

None of the timeA littlle of the timeSome of the timeMost of the timeAll of the time

worthless?

None of the timeA littlle of the timeSome of the timeMost of the timeAll of the time

Is there anything else you would like to tell us, or you think we should know

Financial Counselling Program Intake

Is this an urgent situation (eg. are you close to losing your home, have fines at the 7-day notice stage, are at risk of having utilities disconnected or facing enforced bankrputcy?))

YesNo

If yes, please provide some more information

Who referred you to this service? (eg. Self referral, Centrelink, other THH service, or other external service)

Are you experiencing any of the following (please select all that apply)

Loss of income (temporary)Loss of income (ongoing)Loss of homeLoss of businessLoss of other belongings Paying of bills/utilitiesAccessing relief servicesAccommodation needs Transport needsDifficulty in accessing relief supportsFamily violenceMedical needsOther

What type of financial stress are you experiencing

Credit CardFinesLoansRentMortgage UtilitiesLiving ExpensesMedical expensesPay Day loans BankruptcyInsurance claim BushfiresNoneOther

If Other, Please Specify

If Other, Please Specify

Do you use alcohol or other drugs?

YesNo

Do you gamble?

YesNo

If yes, can you tell us a little bit about your drug or alcohol use?

If yes, how much money would spend on gamblling per week?

What is your household income?

What is your income source? (eg. Centrelink Job seeker, Paid work, etc.)

What is your housing type? (eg. renting, owning with mortgage, living in short term-accommodation, etc.)

Who lives in your household? (eg. spouse/partner, children, roommates, etc.)

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Thank you for getting in touch with us. We will contact you soon to talk about support.

If anything changes, or you would like to speak with us, please call us on: (03) 9865 6700

If you need help right now:

Mental Health Support:

•QLife/Switchboard (3pm-midnight): 1800 184 527

•Lifeline (24/7): 13 11 14

•Beyond Blue (24/7): 1300 224 636

Family Violence Support:

•Safe Steps (24/7): 1800 015 188

•1800 RESPECT (24/7): 1800 737 732

Drug and Alcohol Support:

•DirectLine (24/7): 1800 888 236

•National Drug & Alcohol Helpline (24/7): 1800 250 015

For any emergency: Call 000 for Police, Ambulance or Fire in Australia. 

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