Wellbeing & Support External Provider
Demographic Information
Please enter your passcode to access the electronic demographic form
*
Case sensitive passcode provided by SJA Wellbeing
Your Name
*
First Name
Last Name
Your Email
example@example.com
Your Organisation
*
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Date
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Day
/
Month
Year
Date
Please enter your client reference number below.
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Personal Demographic Classification
Occupational Classification
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Paramedic
Patient Transfer
Communications
Volunteer
Office Support
Family Member
Child of Staff/Volunteer
Employment Status
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Full time
Part time
Casual
Volunteer
Student
Other
You indicated "Other" in this question, please specify the employment status below.
Referral Source
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Self
Wellbeing & Support
Manager
Website
Word of Mouth
Other
You indicated "Other" in this question, please specify the referral source.
Gender
*
Male
Female
Other
If your client wishes to specify, please enter this information below (optional)
Location
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Metro
Regional
Your Clients Age
*
Please Select
Under 18
18-30
31-40
41-50
51-60
Over 60
Length of Service
Please Select
Less that 1 year
1 to 5 years
6-10 years
10-20 years
Over 20 years
Not Applicable
Marital Status
Please Select
Single
Married
Defacto
Divorced
Widowed
Other
Please specify your clients Marital Status below.
Type of Session
*
Please Select
Office Visit
Site Visit
Phone Consult
Telehealth
Other
Please specify the type of session below.
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Primary Reason for Referral
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Alcohol or Drug Problems
Marital Difficulties
Family Issues
Financial Issues
Self Harm / Suicide
Anger
Anxiety
Stress
Trauma
Work-Related Issues
Grief or Loss
Other
Please specify the primary referral reason.
Primary Work Related Issues
*
Conflict with Managers
Conflict with Peers
Bullying
Discrimination
Trauma
Workers Compensation
Injury Management
Perceived Lack of Support
Workload
Stress
Not Applicable or Other
If the primary work issue is either not applicable or other, please specify below.
Type of Treatment Provided
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CBT
Schema Informed Therapy
EMDR
Solution Focussed Brief Therapy
Mindfulness
Interpersonal Psychotherapy
ACT
Relationship Therapy
DBT
Psychoeducation
Hypnotherapy
Other
If the intervention you are providing is not included above, please specify this below.
Please tap Submit below once you have completed the demographic form.
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Administration
Total Number of Sessions
Treatment Period Start Date
/
Day
/
Month
Year
Date
Treatment Period Completion Date
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Day
/
Month
Year
Date
Therapy Goals Achieved
Yes
No
Feedback Form Provided
Yes
No
DASS21 Pre & Post Collected
Yes
No
Email
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