Consumer Registration Form

Please fill out all mandatory fields marked with an asterisk *

PERSONAL DETAILS

Title

First Names*

Surname*

Preferred Name

DOB*

Day

Month

Year

Gender*

What pronoun do you use?

For example: she/her, he/his, they/them
Learn more about pronouns : QHRC : Why pronouns matter.

COMMUNICATIONS

Preferred method of contact?*

Can we email?

Yes No

Home Phone

Please include area code without spaces (e.g. 0299998888).

Can we leave a message for you?

Yes No

Work Phone

If not a mobile, please include area code without spaces (e.g. 0299998888).

Can we leave a message for you?

Yes No

Mobile

Please enter 10 digital number without spaces (e.g. 0499888888).

Can we SMS you?

Yes No

Can we leave voicemail?

Yes No

ADDRESS

Do you have a fixed home address?*

Yes No

Street Address

Address*

Suburb*

State*

Postcode*

Postal Address

Use street address?

Yes No

Address

Suburb

State

Postcode

MEDICARE

Do you have a Medicare Card?

Yes No

Medicare Card No (10 digit card number e.g. 1234567890)

Reference No (the number next to your name)

Expiry Date (e.g. 01/2099)

Health Care Card

Do you have a Health Care Card?

Yes No

HCC Number

HCC Expiry Date (e.g. 01/2099)

EMERGENCY CONTACT / NEXT OF KIN

Next of Kin

Do you have a Next of Kin Contact?*

Yes No

Name*

Relationship*

Phone*

If not a mobile, please include area code without spaces (e.g. 0299998888).

Address*

Can we tell them about your appointment?*

Yes No

Emergency Contact

Do you have an Emergency Contact that is different?*

Yes No

Name*

Relationship*

Phone*

If not a mobile, please include area code without spaces (e.g. 0299998888).

Address*

Can we tell them about your appointment?*

Yes No

CULTURAL BACKGROUND AND ADDITIONAL NEEDS

Are you of Aboriginal or Torres Strait Islander origin?*

Country of Birth*

What cultural or ethnic group do you identify with?*

Ethnicity 1
Ethnicity 2
Ethnicity 3
Ethnicity 4
Ethnicity 5
Ethnicity 6

Do you need an interpreter? If yes, which language?*

Yes No

Language*

HEALTH

Do you have any disabilities and/or additional needs?*

Yes No

If yes, how can we make you comfortable?*

Do you have any allergies?*

Yes No

Allergy	Reaction

Primary Mental Health Data Collection Form

First Names*

Last Names*

DATA COLLECTION CONSENT

We need your consent to give the information you provide below to the government department that funds this program. Your name will not be included. Is this ok with you?

Yes No

If no, please click here to contact us about this.
If you find it hard to fill in this form someone from GPH can assist you, please click here to let us know

PERSONAL DETAILS

TREATMENT INFORMATION

Are you an NDIS Participant?

Yes No

Do you have a Health Care Card or Pensioner Concession Card?

Yes No

MENTAL HEALTH AND ALCOHOL AND OTHER DRUG SERVICES SELF-REFERRAL E-FORM

If this form is being completed by a child or young person’s parent/caregiver, please ensure that all sections are filled out accurately to provide a clear understanding of their needs and concerns.

At GPH, we collect and keep your information safe to safeguard your privacy. You can find more details in our privacy statement. If you prefer not to share your information through this secure platform, please call us to arrange an in-person intake session.

We understand that completing this form may bring up strong emotions. We encourage you to have someone with you as you answer the questions. Sharing your story can enhance the support we provide and help us understand your current situation better.

What is your preferred language?

Is someone helping you fill out this form, or is it being completed by a parent/caregiver or support person?

Yes No

If yes, could you tell us who?

Is this person an interpreter?

Yes No

YOUR PAST HELP AND RECOVERY JOURNEY

This question refers to the help you have received from services not from your friends or family.

SAFETY

If you currently have serious thoughts of self harm please call triple zero (000) or go to your hospital emergency department.

For immediate 24/7 help you can also call the Mental Health Line on 1800 011 511

If you need language support to talk to this service, call the Translating and Interpreting Service (TIS National) on 131 450, state the preferred language, and ask for the Mental Health Line 1800 011 511.

If you are deaf, or have a hearing or speech impairment, you can call the Mental Health Line through the National Relay Service on 1300 555 727

You can also call:

Lifeline 13 11 14
Lifeline Text 0477 131 114
13YARN 13 92 76
Suicide Call Back Service 1300 659 467

YOUR DAY-TO-DAY LIFE

HOW OTHER HEALTH ISSUES AFFECT YOU

In this question, substance use means continuing to drink alcohol, use illegal drugs, or misuse medicines, even when it causes you problems, while cognitive issues may be that you have problems remembering things and solving problems.

THINGS IN YOUR LIFE THAT CAUSES STRESS

FAMILY AND OTHER SUPPORTS

HOW READY ARE YOU TO WORK WITH US?

We’re glad you’ve taking the time to refer yourself to our service. A staff member will be in touch with you as soon as possible. If you have not heard from us in seven days, please call us. Contact details of all our programs can be found at https://www.gph.org.au/services/mental-health/.

Whatever you’re going through, you’re not alone – support is available.

Optional additional information:

The following short test is called the K10. It asks 10 questions about how you’ve been feeling over the past 4 weeks. It will help us to understand what kind of support you might need right now. If you identify as Aboriginal or Torres Strait Islander, a culturally modified scale will be provided when you access our service. GPH K-10 Assessment Form