Participant Information
Fill out the form carefully for registration
Patient Name
*
First Name
Middle Name
Last Name
Birth Date
*
January
February
March
April
May
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July
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September
October
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December
Month
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Day
2023
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1924
1923
1922
1921
1920
Year
Gender
*
Please Select
Male
Female
N/A
Patient Email
*
example@example.com
Contact Number
*
DSM-V Diagnosis: (if you are aware of it)
Current Employment Status
Student
Pensioner
Unemployed
Full-time employed
Part-time Employed
Self-Employed
At Home
Courses
*
Please Select
8-week MBCT course
8-week Adult DBT course
6-week Adolescent DBT course
Do you plan to use your medical aid for payment of this program?
*
No
Yes
Medical Aid
Medical Aid Option
Membership Number
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Your Treating Therapist's Details
Who is your treating psychiatrist?
Where is your psychiatrist located?
Contact details of treating psychiatrist:
Who is your psychologist?
Where is your psychologist located?
Contact details of psychologist:
Who is your GP?
Where is your GP located?
Contact details of GP:
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Clinical Information
What is your main reason for participating in the selected program?
Can you attend weekly sessions and do short daily practices?
*
No
Yes
How many episodes of depression have you had in your life?
One
Two
Three
More than three
Have you ever been admitted to a hospital or clinic for depression?
No
Yes
How many times?
Once
Twice
More than twice
When was your last admission?
*
Have you engaged in self-harm in the last three months?
No
Yes
Please specify
*
Do you use any substances?
No
Yes
Please specify
*
Have you ever had a psychotic episode?
No
Yes
Please specify
*
Have you been diagnosed with PTSD (Post-Traumatic Stress Disorder) or experienced a traumatic
No
Yes
Please specify
*
Do you have any illnesses that cause problems with breathing, or do you have chronic pain?
No
Yes
Please specify
*
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Treatment Plan
Will you be seeing your therapist for the duration of the program?
No
Yes
The purpose of the program is to teach you new skills on how to manage the symptoms of depression. However, the skills trainers are not responsible for your treatment. Therefore, you must have a treating therapist/doctor and an emergency management plan.
*
Yes, I agree
For any queries, please contact us at info@drmelanevanzyl.com.
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