Eclipse Referral Form

Eclipse Referral Form

All information provided here by you is stored electronically in a secure information management system and will be used by Lifeline WA for the purpose of the Eclipse referral process. We will use non-identifying demographic information for reporting purposes. By completing this form, you understand and consent to the use of your information in this way.
ABOUT THE REFERRER
Name*

First NameLast Name
Organisation*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: 0000 000 000.
Email*
example@example.com
Relationship to the Applicant*
ABOUT THE APPLICANT
Your Name*

First NameLast Name
Your Preferred Name
Your Date of Birth*
Your Age*
Your Gender
Your Preferred Pronouns
Phone Number*
Please enter a valid phone number.Format: 0000 000 000.
Email*
example@example.com
Are you of Aboriginal or Torres Strait Islander Australian decent?*
Country of Birth*
Main language spoken at home*
Your Emergency Contact*

First NameLast Name
Your Emergency Contact Relationship*
Emergency Contact Phone Number*
Please enter a valid phone number.Format: 0000 000 000.
YOUR RESIDENTIAL ADDRESS*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is this the address where you will be attending online?*

YesNo
Is this the address where we send you materials?*

YesNo
THE ADDRESS OF WHERE I WILL BE ATTENDING ONLINE*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
THE ADDRESS WHERE MY MATERIALS CAN BE SENT TO*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you have a private space to engage in the group sessions uninterrupted?*

YesNo
.Have you participated in a support group before?*

YesNo
Please tell us about it
Do you have any sensory needs? e.g.: related to vision, hearing or other senses.*

YesNo
Please tell us how we can help you.
The group runs for 8 weeks, once a week for 3 hours at a time. Thinking about your strengths and how you respond under pressure, do you think there will be any barriers to you engaging in the group?*

YesNo
What could some of those barriers be?

Work commitmentsFamily commitmentsNo child careInternet connectionHealth issuesOther
What do you hope to gain from this group?*

Rows	Yes	No
Do you have a working laptop with a camera and microphone?
Do you have access to a reliable internet service?
If no to either question above, is there a way you can access either?
Have you participated in virtual workshops before?
Do you need support accessing Zoom?

Are you in the care of a Health Professional?*

YesNo
Health Professional 1
Health Professional 2
Health Professional 3
Health Professional 4
Are you receiving any other support?*

YesNo
Support 1
Support 2
Have you ever attempted suicide?*

YesNo
When was your last attempt?*
Are others of aware of this attempt?*

YesNo
Have you ever planned to suicide without acting on your plans?*

YesNo
How did you hear about us?*

GPWeb searchSelfFriend / familyCommunity CentreMental Health Care ProfessionalOther
By signing this form, you understand and consent to the use of your information being used for the purposes outlined. You also give permission to Lifeline WA to contact the health care professional(s) listed above if necessary.
Referrer Signature*
Applicant Signature*
For information about Jotform’s Privacy and Security, please see the following links.

Jotform Privacy

Jotform Security
Should be Empty: