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Mental Health Intake Survey Form
Please fill the form below
During high school, have you had any concerns about your mental health eg stress, anxiety, low mood:
Yes
No (you can bail out now or keep going to help with suggestions)
I was worried about/supported a friend
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Who has supported you/your friend with mental health stuff:
Teacher
School counsellor
Friend
BF/GF
Parent
Professional
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If you didn't get support but wish you could have, what sort would you have liked:
Private individual therapy
A group program to share and learn
A doctor
A school staff member
Online counselling
Email access to a therapist
This field is required.Please enter value
If you have had contact with a school counselor, please comment on whether it was helpful or unhelpful and why:
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Did you feel you had enough understanding and information on the problem:
Yes
No
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Date:
This field is required.Please enter value
Date format is invalid, please check it again
The value must be greater than or equal to -21474836487
The value must be less than or equal to 2147483647
Name:
First Name
Last Name
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This field is required.Please enter value
Email Id:
This field is required.Please enter value
Please enter valid email address
Mobile No:
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Invalid phone number.
The value must be less than or equal to 20
Signature:
This field is required.Please enter value
Submit
