Request Counselling support Survey

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* 4. Email?

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* 5. District currently residing in

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* 6. Aboriginal or Torres Strait Islander?

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* 7. Are you currently homeless (incl couch surfing)?

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* 8. Others currently residing in household


Mum	Mum menu
Dad	Dad menu
Partner of parent / step-parent	Partner of parent / step-parent menu
Grandparent	Grandparent menu
Brother(s) (inc step, half etc)	Brother(s) (inc step, half etc) menu
Sister(s) (inc step, half etc)	Sister(s) (inc step, half etc) menu
Partner	Partner menu
Housemate	Housemate menu
Other	Other menu

Please specify if 'Other' was selected

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* 9. What are the main areas you would like Menslink to help with?

	Low priority	Medium priority	High priority
Confidence & self-esteem	Confidence & self-esteem Low priority	Confidence & self-esteem Medium priority	Confidence & self-esteem High priority
General happiness and/or depression and sadness	General happiness and/or depression and sadness Low priority	General happiness and/or depression and sadness Medium priority	General happiness and/or depression and sadness High priority
Relationships (partner)	Relationships (partner) Low priority	Relationships (partner) Medium priority	Relationships (partner) High priority
Relationships (friends)	Relationships (friends) Low priority	Relationships (friends) Medium priority	Relationships (friends) High priority
Relationships (family)	Relationships (family) Low priority	Relationships (family) Medium priority	Relationships (family) High priority
Managing strong emotions (like anger)	Managing strong emotions (like anger) Low priority	Managing strong emotions (like anger) Medium priority	Managing strong emotions (like anger) High priority
Anxiety and/or stress	Anxiety and/or stress Low priority	Anxiety and/or stress Medium priority	Anxiety and/or stress High priority
Bullying	Bullying Low priority	Bullying Medium priority	Bullying High priority
Resilience (not getting upset when things don't go well)	Resilience (not getting upset when things don't go well) Low priority	Resilience (not getting upset when things don't go well) Medium priority	Resilience (not getting upset when things don't go well) High priority
Alcohol or drug use	Alcohol or drug use Low priority	Alcohol or drug use Medium priority	Alcohol or drug use High priority
Grief or loss	Grief or loss Low priority	Grief or loss Medium priority	Grief or loss High priority
After effects of a traumatic event/time in your life (PTSD)	After effects of a traumatic event/time in your life (PTSD) Low priority	After effects of a traumatic event/time in your life (PTSD) Medium priority	After effects of a traumatic event/time in your life (PTSD) High priority
Spending too much time online (social media, games, porn)	Spending too much time online (social media, games, porn) Low priority	Spending too much time online (social media, games, porn) Medium priority	Spending too much time online (social media, games, porn) High priority

Other (please specify)

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* 10. Ever been affected by any of the following?

Depression

Anxiety

ADHD

Autism / Aspergers

Dyslexia

Personality disorder (e.g. Antisocial, Paranoid, Obsessive-compulsive disorders)

Psychotic disorder (e.g. Schizophrenia)

Post Traumatic Stress Disorder (PTSD)

Oppositional Defiance Disorder (ODD)

Physical disability (please provide details below)

Other (please specify)

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* 11. Please indicate if you have ever been affected by:

	As a direct victim	As an indirect victim / witness	Have done it yourself
Family or domestic violence: Physical	Family or domestic violence: Physical As a direct victim	Family or domestic violence: Physical As an indirect victim / witness	Family or domestic violence: Physical Have done it yourself
Family or domestic violence: Psychological / emotional abuse (e.g. verbal abuse, intimidation, control)	Family or domestic violence: Psychological / emotional abuse (e.g. verbal abuse, intimidation, control) As a direct victim	Family or domestic violence: Psychological / emotional abuse (e.g. verbal abuse, intimidation, control) As an indirect victim / witness	Family or domestic violence: Psychological / emotional abuse (e.g. verbal abuse, intimidation, control) Have done it yourself
Sexual abuse	Sexual abuse As a direct victim	Sexual abuse As an indirect victim / witness	Sexual abuse Have done it yourself
Other violence (school, on the street etc)	Other violence (school, on the street etc) As a direct victim	Other violence (school, on the street etc) As an indirect victim / witness	Other violence (school, on the street etc) Have done it yourself
Psychological / emotional violence (e.g. verbal abuse, intimidation, control)	Psychological / emotional violence (e.g. verbal abuse, intimidation, control) As a direct victim	Psychological / emotional violence (e.g. verbal abuse, intimidation, control) As an indirect victim / witness	Psychological / emotional violence (e.g. verbal abuse, intimidation, control) Have done it yourself

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* 12. Please indicate whether you have been affected by any of the following:

Frequent thoughts or making plans about suicide

Suicide attempt

Suicide (completed or not) of family member or close friend

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* 13. Are you currently using any other services?

Other (please specify)

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* 14. Please give us some general background including how think we can best support you

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* 15. Is there anything else, including any legal issues we should be aware of?

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* 16. How did you find out about Menslink?

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* 17. By ticking this box I consent to Menslink collecting personal data for anonymous statistical purposes and storing this information offshore.

Yes

Request Counselling support

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* 1. Name

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* 2. Age (don't forget our age restrictions)

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* 3. Contact number

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* 4. Email?

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* 5. District currently residing in

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* 6. Aboriginal or Torres Strait Islander?

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* 7. Are you currently homeless (incl couch surfing)?

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* 8. Others currently residing in household

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* 9. What are the main areas you would like Menslink to help with?

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* 10. Ever been affected by any of the following?

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* 11. Please indicate if you have ever been affected by:

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* 12. Please indicate whether you have been affected by any of the following:

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* 13. Are you currently using any other services?

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* 14. Please give us some general background including how think we can best support you

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* 15. Is there anything else, including any legal issues we should be aware of?

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* 16. How did you find out about Menslink?

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* 17. By ticking this box I consent to Menslink collecting personal data for anonymous statistical purposes and storing this information offshore.