Intake Form - Adult

This enquiry form is specifically for the Northern Sydney PHN funded program: HeadStart.

HeadStart consists of online modules covering 6 key mental health steps and time with a provisional psychologist to implement personalised mental health care strategies. It is a low intensity-low cost service for GP referred patients who are suitable.

HeadStart is ONLY for people (aged 18+) who live, work or study within the Northern Sydney PHN (click on link to see map). It is intended for individuals who do not need to see a psychologist but are still struggling with life stressors and adjustments, low grade burnout and/or anxiety. HeadStart can offer additional support to help you get on top of your wellbeing.

HeadStart is NOT suitable for you if you are currently experiencing moderate to significant levels of distress. If you have frequent periods of teariness, consistent lack of appetite, panic attacks and your daily functioning is impacted, this programme may not be for you. If you are unsure, please refer to the mood and anxiety scales below. For individuals experiencing these increased levels of distress, please complete the CFEL's enquiry form for psychology appointments here.

If you require emergency or crisis attention please contact The Mental Health Line on 1800 011 511 or dial 000. The LifeLine number is 131114.
Enquiry Form - HeadStart Adult
Full Name *

First Name Last Name
Email *
example@example.com
Phone Number *
Suburb *
Date of Birth *

Month Day Year
DD/MM/YYYY
Occupation *
Where did you hear about us? *

GP Friend or Family Member Web Search Social Media Other
GP/Medical Practice Name
GP Phone Number *
Please enter a valid phone number.
Indicate your overall mood in the past two weeks *

1

2

3

4

5

6

7

8

9

10

1 is Lowest/ Worst, 10 is Highest / Best
Anxiety is a state of nervousness, worry and unease. Indicate your overall anxiety over the past two weeks. *

1

2

3

4

5

6

7

8

9

10

1 is None / Low, 10 is Extreme / High
Please Note: If you rated yourself on mood 5 or below, or on anxiety 7 or above HeadStart may not be suitable to best provide care for your current needs.

If this is you, please proceed to CFEL's enquiry form for psychology appointments here.

If you require emergency or crisis attention please contact The Mental Health Line on 1800 011 511 or dial 000. The LifeLine number is 13 11 14.
Please briefly describe your current concerns / reason for referring for HeadStart *
Have you previously received a mental health diagnosis? *

Yes No
If you selected 'Yes' for the option above, please describe;
Stress is the extent to which you feel overwhelmed or unable to cope with responsibilities/pressures. Indicate your stress over the past two weeks. *

1

2

3

4

5

6

7

8

9

10

1 is None/ Low, 10 is Extreme / High
Is there any other information you would like us to know related to your enquiry?
Thank you for completing this form. Please click 'submit' below, and our intake team will be in touch shortly. Thank you.
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Enquiry Form - HeadStart Adult