AFL - EAP Questionnaire - Connect Psych Services

Name *

First

Last

Please provide best email in case of issue during this booking process? *

*Please note this is used only for administration and not to identify you with your employer.

Please enter the code provided by your sponsoring company. *

This code is non-identifiable and is required to validate access.

Which State / Territory / Location are you? *

Please detail if not listed above

What is your Gender? *

Male
Female
Other

How old are you? *

Would you prefer a male or female therapist ? *

Male
Female
Either Male or Female

Specialist Practitioner Support, Please let us know if there are additional considerations:

ATSI (Aboriginal and Torres Strait Islander )
LGBTIQ+
Eldercare
Disability and Carers
Domestic and Family Violence

Please select your primary reason why you would like counselling? *

If Other, Please Describe

Please select any secondary reasons why you would like discussed?

If Other, Please Describe:

Are these reasons relating Work or Personal related pressures? *

Please list anything else you would like to address?

a. Over the past two weeks how often have you been bothered by trouble falling asleep, staying asleep or sleeping too much? *

Not at all
Several days
More than half the days
Nearly everyday

b. In the past four weeks about how often did you feel tired out for no good reason? *

None of the time
A little time
Some of the time
Most of the time
All the time

c. In the past four weeks about how often did you feel nervous? *

None of the time
A little time
Some of the time
Most of the time
All the time

d. In the past four weeks about how often did you feel so nervous that nothing could calm you down? *

None of the time
A little time
Some of the time
Most of the time
All the time

e. In the past four weeks about how often did you feel hopeless? *

None of the time
A little time
Some of the time
Most of the time
All the time

a. In the past four weeks about how often did you feel restless or fidgety? *

None of the time
A little time
Some of the time
Most of the time
All the time

b. In the past four weeks about how often did you feel so restless you could not sit still? *

None of the time
A little time
Some of the time
Most of the time
All the time

c. In the past four weeks about how often did you feel depressed? *

None of the time
A little time
Some of the time
Most of the time
All the time

d. In the past four weeks about how often did you feel that everything was an effort? *

None of the time
A little time
Some of the time
Most of the time
All the time

e. In the past four weeks about how often did you feel so sad that nothing could cheer you up? *

None of the time
A little time
Some of the time
Most of the time
All the time

f. In the past four weeks about how often did you feel worthless? *

None of the time
A little time
Some of the time
Most of the time
All the time

Thank You 😀. Next step is to be matched against a number of Therapists whom you will be able to book a time & date that suits you. If there is anything else you would like us to consider, please enter 👇 otherwise continue to make a booking....

Please note you will be required to re-enter your name and contact details once you have selected your Therapist. This is needed to ensure your Therapist receives your details in the required format.

Tell Us A Little About You

Help us get to know you better to assist us to match you to with the best therapist.
Rest assured your details and honest answers remain confidential.

Tell Us A Little About You

Help us get to know you better to assist us to match you to with the best therapist.Rest assured your details and honest answers remain confidential.

Help us get to know you better to assist us to match you to with the best therapist.
Rest assured your details and honest answers remain confidential.