Online Assessment

You can send us your details if you prefer and we will ring you to organise an appointment that is suitable.
Full Name:
Home Ph:
Mobile Ph:
Email:
Street Address:
Suburb/Town:
Postcode:	Country:
Date of Birth:
Country of Birth:
Are you:	male
	female
Previous Treatment Experience
Have you had any treatment in the past? no yes. If yes tick the appropriate box.
	Received Counselling?
	Completed a Detoxification?
	Attended a Rehabilitation program?
	Seen a Doctor for your issues?
	Seen a Psychiatrist?
	Prescribed Medication?
Any further details?
Have you ever been diagnosed with...
	Depression?
	Anxiety?
	Bipolar?
	Post Traumatic Stress Disorder (PTSD)?
	(Any) Personality Disorders?
	Drug Induced Psychosis?
	Schizophrenia?
	Bulimia?
	Anorexia Nervosa?
Have you ever been prescribed medication for any of the above? no yes
Are you currently taking prescribed medication for any of the above? no yes
What's the medication called?
Do you suffer from any medical conditions? no yes
What's medical condition do you suffer from?
Any Drugs and Alcohol problems?
What is your drug of choice?
What other drugs do you use on a regular basis?

How long ago did you start using (in years)?
How often do you use?
How much does drugs cost you per week?
Are you currently detoxed? Give details of how long you have now abstained and where did you detox?

Why are you seeking treatment?
What brought you to seek treatment now?

What are your reasons for choosing The Marcon Emotional Balance Centres?


What are you hoping to achieve by doing the counselling and/or program?

Your safety concerns
Have you ever thought of harming yourself? no yes
Have you ever attempted suicide? no yes
If yes, what did you do:

Is this a problem for you at the moment? no yes
If you are currently experiencing suicide or self-harm ideation, please ring a you family member, a friend, or ring your local hospital.
Other information
Is there anything else you would like us to know about?

Thank you for your honesty and patience... We will be in contact with you shortly to discuss how we can best help you.