UniWellbeing Registration Form

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UniWellbeing Program

Complete this form to access clinician supported online program.

Please note this is not a crisis service. You will be contacted within 3-4 working days. If you require immediate help or medical attention, contact:

On-campus: +61 (2) 9850 9999 (Security)
Off-campus: 000 (Emergency Services)
After hours support and assistance: 1800 CARE MQ (1800 2273 67)

Are you wanting to enrol into the online UniWellbeing program?*

Yes No

If you are seeking to discuss alternative counselling supports, please complete the Care Report. You will be contacted by a Student Wellbeing staff member to discuss your support needs.

Name*

First Name

Last Name

Preferred pronoun

Student ID*

Phone*

Student Email (...@students.mq.edu.au)*

Are you of Aboriginal or Torres Strait Islander origin?

Yes No Prefer not to say

How did you hear about UniWellbeing?*

During the past TWO (2) WEEKS, how much (or how often) have you been bothered by the following problems?*

During the past TWO (2) WEEKS, how much (or how often) have you been bothered by the following problems?
	NONE (NOT AT ALL)	SLIGHT (LESS THAN A DAY OR TWO)	MILD (SEVERAL DAYS)	MODERATE (MORE THAN HALF THE DAYS)	SEVERE (NEARLY EVERY DAY)
1)Thoughts of actually hurting yourself?	During the past TWO (2) WEEKS, how much (or how often) have you been bothered by the following problems?: 1)Thoughts of actually hurting yourself? (NONE (NOT AT ALL))	1)Thoughts of actually hurting yourself? (SLIGHT (LESS THAN A DAY OR TWO))	1)Thoughts of actually hurting yourself? (MILD (SEVERAL DAYS))	1)Thoughts of actually hurting yourself? (MODERATE (MORE THAN HALF THE DAYS))	1)Thoughts of actually hurting yourself? (SEVERE (NEARLY EVERY DAY))
2) Hearing things other people couldn't hear, such as voices even when no one was around?	2) Hearing things other people couldn't hear, such as voices even when no one was around? (NONE (NOT AT ALL))	2) Hearing things other people couldn't hear, such as voices even when no one was around? (SLIGHT (LESS THAN A DAY OR TWO))	2) Hearing things other people couldn't hear, such as voices even when no one was around? (MILD (SEVERAL DAYS))	2) Hearing things other people couldn't hear, such as voices even when no one was around? (MODERATE (MORE THAN HALF THE DAYS))	2) Hearing things other people couldn't hear, such as voices even when no one was around? (SEVERE (NEARLY EVERY DAY))

Have you experienced violence or abuse within the last month?*

Yes No

Should we be worried about your safety now?*

0 - No (I am not planning on hurting myself or taking my own life) 1 2 3 4 5 - Yes (I am seriously planning on taking my own life)

If you need urgent assistance, then here are some numbers that can be helpful:

call triple zero '000’ (24Hrs/7 days) for a threat to life or other medical emergency

call Mental Health Line '1800 011 511’ (24Hrs/7 days) for free mental health support

call Lifeline ’13 11 14’ for free, confidential telephone counselling

present in person to a hospital emergency department.

What are 3 things you hope will improve after participating in the UniWellbeing Program?*

Please click here for the CWB Privacy Information Statement.