Mental health form - Living Valley

Due to high demand, please call or email reception@livingvalley.com.au for January bookings (online availability may not be accurate).

Living Valley

Mental Health Questionnarie

CONFIDENTIALITY

Living Valley is committed to the health and safety of its guests. As part of this commitment, this questionnaire is required to be completed prior to arrival at the first counselling appointment. The completed form will only be seen by staff members where necessary, unless in need of immediate medical attention, in which case relevant details will be given to the appropriate medical officer.

Your completion of this form will help us in our quest to meet your expectations. Please allow approximately 15 minutes to complete as progress is unable to be saved! Please note: All content is sent over a secure HTTPS connection.

Mental Health Form (New)

First Name

Last Name

Date of birth:

Date of program

1. Current Treatment

Are you currently working with any Mental Health Practitioner (e.g. Psychologist, Psychiatrist, Social Worker, Counselor etc...)?*

Yes

Have you previously seen a Mental Health Practitioner (e.g. Psychologist, Psychiatrist, Social Worker, Counselor etc...)?

Yes

Are you currently taking any psychiatric medications, vitamins, supplements etc (over the counter or prescribed)

Yes

Details of current medications

2. Mental Health History

Was a clinical diagnosis made to you by a psychologist, psychiatrist or other practitioner?*

Yes

3. Current Concerns & Difficulties

Please indicate on a scale of 1 - 5 how much these feelings negatively impact your life (where 1 = the feelings have no real impact on the way l live my life and 5 = the feelings dominate how l live my life)

BEHAVIOUR IMPACT

Are you currently experiencing any suicidal thoughts?

Yes

4. Goals

What are the main goals that you hope to achieve through your stay at the retreat (retreat guests only)?

In order to ensure that the session are most beneficial to you, please described what you would most like to gain or achieve through psychological therapy?

What qualities do you like most about yourself?

Please read each statement and select a number 0, 1, 2 or 3 which indicates how much the statement applied to you over the past week.

The rating scale is as follows:
0 = Did not apply to me at all
1 = Applied to me to some degree, or some of the time
2 = Applied to me to a considerable degree, or good part of the time
3 = Applied to me very much, or most of the time

	0	1	2	3
I found it hard to wind down
I was aware of dryness of my mouth
I couldn't seem to experience any positive feeling at all
I experience breathing difficulty (eg. excessive rapid breathing, breathlessness in the absence of physical exertion)
I found it difficult to work up the initative to do things
I tended to over-react to situations
I experienced trembling (eg. in the hands)
I felt that l was using a lot of nervous energy
I was worried about situations in which l might panic and make a fool of myself
I felt that l had nothing to look forward to
I found myself getting agitated
I found it difficult to relax
I felt down-hearted and blued
I was intolerant of anything that kept me from getting on with what l was doing
I felt l was close to panic
I was unable to become enthusiastic about anything
I felt l wasn't worth much as a person
I felt that l was rather touchy
I was aware of the action of my heart in the absence of physical exertion (eg. sense of heat rate increase, heart missing a beat)
I felt scared without any good reason
I felt that life was meaningless

We’re looking forward to welcoming you to Living Valley.

Our team will take the time to carefully review the information you’ve shared so we can ensure your stay is tailored to you from the moment you arrive. Every part of your experience is designed to support you, so you can feel at ease, cared for and able to fully switch off.

If you have any questions before your stay, or if anything changes, please don’t hesitate to reach out. We’re here to help and will support you every step of the way.

@LivingValley

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