Welfare Form, Macquarie University

Welfare Form

Welfare Screening Guide

Clinician *
Name * First Last
Student ID *
Contact Number
*
Email *
Checkboxes *
Financial assistance (scholarships, loans/grants) Tuition fees Centrelink payments Other financial concerns Landlord problems Other accommodation concerns Work-related problems Legal concerns Study problems Relationship concerns Mental health (e.g. anxiety/low mood) Emotional distress (e.g. anger/grief) Thoughts of hurting yourself Sexual assault/harrassment
If you require immediate support for sexual assault / harassment:

* Call 1800 RESPECT (1800 737 732) for free, confidential, 24/7 assistance.

* Call Royal North Shore Hospital and ask to speak with the sexual assault counsellor on call.

* More information is available at Respect.Now.Always.

This is the description of your section break.
What specific information or help are you hoping that Campus Wellbeing & Support Services will be able to provide? *
How long have you been experiencing your current difficulties? *
First option Past week Past fortnight Past month Past semester More than 6 months
Have you been referred by anyone for this appointment? *
Self-Referral Student Connect Academic/Faculty Campus Wellbeing Other - University Department Other - External Other - Please Specify
Have you previously presented to Campus Wellbeing & Support Services for assistance? *
Yes No
Is today's appointment related to the same issue/s? *
Yes No
Have you experienced violence or abuse within the last month? *
Yes No
If comfortable, please provide the details.
Have you ever tried to kill yourself or hurt yourself on purpose? *
Yes No
If comfortable, please provide the details.
Should we be worried about your safety now? *
0 - No (I am not planning on hurting myself or taking my own life) 1 2 3 4 5 - Yes (I am seriously planning on taking my own life)
Thinking about your own life and personal circumstances, how satisfied are you with your life as a whole? *
0 - :( 1 2 3 4 5 6 7 8 9 10 - :)
Please include in this space anything else you feel it is important for us to know. (Optional)

Have you received help in the past with your current issue, who has provided this? How sucessful was the experience? (Optional)
	Haven't used	Wasn't helpful	Partially helpful	Very helpful
GP
Academics
Mentors
Residential Advisors
Friends & Family


	Haven't Used	Wasn't Helpful	Partially Helpful	Very Helpful
Counsellor / Psychotherapist
Psychologist
Psychiatrist
Mental Health Team

Please provide your consent to our collection, use and disclosure of your personal information by ticking the boxes below. *
I consent to the Campus Wellbeing and Support Service collecting, using and disclosing my personal information as described in the Privacy Collection Statement. I consent to the Campus Wellbeing and Support Service collecting my personal information from, or disclosing my personal information to, other health professionals involved in my care.

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Macquarie University

Welfare Form

If you require immediate support for sexual assault / harassment: * Call 1800 RESPECT (1800 737 732) for free, confidential, 24/7 assistance. * Call Royal North Shore Hospital and ask to speak with the sexual assault counsellor on call. * More information is available at Respect.Now.Always.

Explore Macquarie

If you require immediate support for sexual assault / harassment:

* Call 1800 RESPECT (1800 737 732) for free, confidential, 24/7 assistance.

* Call Royal North Shore Hospital and ask to speak with the sexual assault counsellor on call.

* More information is available at Respect.Now.Always.