Afiya InMind Consultation Form

What is your full name?* This field is required.

First Name

Last Name

What is your email address?* This field is required.

example@example.com

What is your phone number?* This field is required.

Area Code

Phone Number

Are you of the Muslim faith?* This field is required.

Yes

What is your gender?* This field is required.Your gender identity is an important part of your lived experience. Sharing it helps us tailor our support to your specific needs.

Male

Female

What is your age?* This field is required.

What is your relationship status?* This field is required.

Single

Married

Divorced

Do you consider yourself to be spiritual?* This field is required.

Yes

Have you ever been in therapy before?* This field is required.Knowing your history with therapy helps us build the right plan for you. If you’re new to this, we’ll inform you on what to expect once you've signed up.

Yes

What led you to consider therapy today?* This field is required.This is just a starting point to help us understand what’s on your mind. You’ll have plenty of time to share more details about your feelings and challenges as we move forward. Select all that apply.

I've been feeling depressed

I've been feeling anxious or overwhelmed

My mood is interfering with my job / studies performance

I struggle with building or maintaining relationships

I can't find purpose or meaning in my life

I am grieving

I have experienced trauma

I need to talk through a specific challenge

I want to gain self confidence

I want to improve myself and don't know where to start

Recommended to me (family, friend, doctor)

Just exploring

I need help with my marriage / relationship

I have a GP referral

I need a psychological assessment

I need help with parenting skills

What are your expectations from your therapist?* This field is required.A therapist who... Select all that apply.

Listens

Explores my past

Teaches me new skills

Challenges my beliefs

Assigns me homework

Guides me to set goals

I have experienced trauma

Proactively checks in with me

Helps me cope with difficulties

I need a diagnostic assessment

Reduces my symptoms

I don't know

Other

Would you prefer a therapist who is gentle or direct?* This field is required.

Gentle

Somewhat gentle

No preferences

Somewhat direct

Direct

Would you prefer a therapist who is flexible or structured?* This field is required.

Flexible

Somewhat flexible

No preferences

Somewhat structured

Structured

Would you prefer a therapist who is casual or formal?* This field is required.

Casual

Somewhat casual

No preferences

Somewhat formal

Formal

How would you rate your physical health?* This field is required.Your physical and mental health are connected. Knowing how you feel physically helps your therapist provide more holistic and well-rounded support.

Good

Fair

Poor

Are you currently experiencing overwhelming sadness, grief, or depression?* This field is required.Sharing how you've been feeling helps your therapist use the most effective, proven methods to help you feel better and manage your health.

Yes

How would you rate your current eating habits?* This field is required.

Good

Fair

Poor

Over the past 2 weeks, how often have you been bothered by little interest or pleasure in doing things?* This field is required.

Not at all

Several days

More than half the days

Nearly every day

Over the past 2 weeks, how often have you been bothered by moving or speaking so slowly that other people could have noticed?* This field is required.Or the opposite - being so fidgety or restless that you have been moving around a lot more than usual.

Not at all

Several days

More than half the days

Nearly every day

Over the past 2 weeks, how often have you been bothered by feeling down, depressed or hopeless?* This field is required.

Not at all

Several days

More than half the days

Nearly every day

Over the past 2 weeks, how often have you been bothered by trouble falling asleep, staying asleep, or sleeping too much?* This field is required.

Not at all

Several days

More than half the days

Nearly every day

Over the past 2 weeks, how often have you been bothered by feeling tired or having little energy?* This field is required.

Not at all

Several days

More than half the days

Nearly every day

Over the past 2 weeks, how often have you been bothered by poor appetite or overeating?* This field is required.

Not at all

Several days

More than half the days

Nearly every day

Over the past 2 weeks, how often have you been bothered by trouble concentrating on things, such as reading the newspaper or watching television?* This field is required.

Not at all

Several days

More than half the days

Nearly every day

Over the past 2 weeks, how often have you been bothered by thoughts that you would be better off dead or of hurting yourself in some way?* This field is required.

Not at all

Several days

More than half the days

Nearly every day

How difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?* This field is required.

Not at all

Several days

More than half the days

Nearly every day

Are you currently employed?* This field is required.

Yes

Do you have any problems or worries about intimacy?* This field is required.

Yes

How often do you drink alcohol?* This field is required.

Never

Infrequently

Monthly

Weekly

Daily

When was the last time you thought about self-harm or wishing you were not alive?* This field is required.

Never

Over a year ago

Over 3 months ago

Over a month ago

Over 2 weeks ago

In the last two weeks

Are you currently experiencing anxiety, panic attacks or have any phobias?* This field is required.Some symptoms of panic attacks include a racing heart, dizziness, or chest pains.

Yes

Are you currently experiencing any chronic pain?* This field is required.

Yes

How would you rate your current financial status?* This field is required.

Good

Fair

Poor

How would you rate your current sleeping habits?* This field is required.Your sleep habits and anxiety often go hand in hand. Sharing this helps your therapist create a more complete plan to help you feel rested and at ease.

Good

Fair

Poor

Are there any specific preferences for your therapist?Select all that apply.

Male therapist

Female therapist

Older therapist (45+)

Religious therapist

Who referred you to Afiya InMind?* This field is required.

Google Search

Instagram

Facebook

Friend or family member

GP / medical doctor

Afiya InMind (services).Select all that apply.

I want to see a counsellor and I know there is a fee to be paid

I need to specifically see a psychologist and know fees are to be paid

I have private health fund

I have an NDIS Plan

I will be paying privately

I want specialist marriage/relationship therapy

I am being referred for the Workers Injury Insurance Scheme

I am being referred for CTP / Motor Vehicle Accident insurance scheme

I am aware that there is limited or no bulk-billing services.

I prefer admin contact me via phone

I prefer admin contact me via email

I need an interpreter

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