Referrers Details
Date of Referral:	Referrers Name:
Organisation:	Phone Number:
Email:
Does the client consent to referral? FocusOne Health is a voluntary service and all clients must consent to and be willing to engage in services	Yes No
Client Details
Name:	DOB:	Age:
Gender:	Male	Female	Other	Not stated
Address:
Home Phone:	Mobile:
Email:
GP:	When did you last see a Dr?
In case of Emergency contact	Name:	Phone:
Do you identify as:	Aboriginal	Torres Strait Islander
Country of Birth:	Other (please state):
Do you speak a language other than English?	No	Yes (please state)
Ability to speak English	Very Well	Well	Not Well	Not At All
Do you live alone:	Yes	No (with whom)
Accommodation:	Unstable	No fixed address
Marital Status:	Single	Married	Defacto	Other:
Occupation Status:	Unemployed	Employed Full-time Casual Employed Part-time	Studying F/T Studying P/T
Occupation:
Education Level:

Are you currently engaging with or being supported by any other services?	Yes No
If YES, please explain:
What are the main issues of concern at the moment? Greatest Problem Second greatest problem (if applicable) ________________________________________________________________________________________________ __________________________________________________________________________________________ ________________________________________________________________________________________________
Over the last two weeks how often have you been bothered by any of the following problems Not at all Several Days More than half the days Nearly everyday Little interest or pleasure in doing things 0 1 2 3 Feeling down, depressed or hopeless 0 1 2 3 Over the last two weeks how often have you been bothered by any of the following problems Not at all Several Days More than half the days Nearly everyday Feeling nervous, anxious or on edge 0 1 2 3 Not being able to stop or control worrying 0 1 2 3