Pre-Admission eForm

First Name

Last Name

Date of Birth

Address

E-Mail Address *

Phone Number *

Which pronouns do you use?

He/His/HimShe/Hers/HerThey/Theirs/ThemOther

Other:

Details:

Do you consent to SPP contacting your Health Care Professional?

Name

Profession

Practice Name

Practice Telephone number

Practice Address

What are you seeking treatment for?

Health Fund

Health Fund number

Indigenous Status *

Country of Birth *

Do you have a current medical condition?

YesNo

Has your medical condition required hospitalisation?

YesNo

Are you currently at another hospital or have been in the last 14 days?

YesNo

Are you actively having thoughts of suicide?

YesNo

Please call LifeLine at 13 11 14 or emergency services at 000, or present to your local hospital immediately

Do you currently have a fixed residential address?

YesNo

heightdiv

heightsq

Height (cm)

Weight (kg)

Calculated BMI

Please carefully read the following to see if any apply to your current situation:

Are you currently admitted involuntarily to a facility?
Do you have a BMI at or below 18?
Do you have an eating disorder or are actively restricting, binging or purging?
Do you have a diagnosis of schizophrenia or schizoaffective disorder?
Have you ever heard voices or had other types of hallucinations, either whilst sober or under the influence? OR Do you currently have drug induced psychosis?
Do you have any current forensic issues or ongoing court proceedings?
Do you need to be bailed to a facility ?

Yes, one or more apply to meNo to all

Is there anything else you would like us to know about you?

A member of our Intake Team will call you in the next 24 hours to discuss the next step

Do you have a regular GP?

YesNo

Do you consent to SPP contacting your GP?

Name

Practice Name

Practice Number

Practice Address

Do you have a treating psychiatrist?

YesNo

Do you consent to SPP contacting your Psychiatrist?

Name

Practice Name

Practice Number

Practice Address

Do you have a counsellor/psychologist/therapist?

YesNo

Do you consent to SPP contacting them?

Name

Practice Name

Practice Number

Practice Address

Do you have any other active professional supports?

YesNo

Do you consent to SPP contacting them?

Name

Practice Name

Practice Number

Practice Address

Details

Have you ever done the 12 step program before?

YesNo

Details

Who do you live with?

Do you have children?

YesNo

Mental Health

Have you been experiencing any of the following?

Feelings of sadness, depressed mood, irritability?Insomnia/Hypersomnia, Early Morning Waking?Fatigue or loss of energy every day?Diminished ability to think or concentrate/indecisivness?Increased/Decreased appetite?Feeling physically slow or agitated?Feelings of worthlessness/excessive inappropriate guilt?Pre-occupation with death or suicide?

In the last three (3) months, what's the longest period you have gone without drugs or alcohol?

How many times have you tried to detox?

What is your goal around your drug and alcohol use?

Do you smoke?SPP is strictly a non-smoking facility. Support is given for Nicotine Replacement Therapy during your stay

Dietary Requirements

Do you have any specific dietary requirements?

YesNo

Details

Medication

Are you taking any medication? If so, how many?

Name

Dose

How often?

What is this for?

Prescription length

Name

Dose

How often?

What is this for?

Prescription length

Name

Dose

How often?

What is this for?

Prescription length

Name

Dose

How often?

What is this for?

Prescription length

Name

Dose

How often?

What is this for?

Prescription length

Goal of Treatment

What are your goals for treatment, and when would you like treatment to commence?

Is there anything else you would like to share about yourself or in regards to your admission?

Please attach additional information (discharge summaries, medication list or referrals)

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Preferred appointment time *