Full Name Date of Birth Phone Number Email Address Department/Agency Role/Position

Contact Name Relationship Phone Number

How did you hear about this service? Briefly describe the primary reason for seeking mental health support

Years of Service Typical Work Schedule Have you been involved in any critical incidents recently? Yes No If yes, please provide details

Previously diagnosed mental health conditions Current medications (if any) Are you currently receiving any mental health treatment? Yes No If yes, please describe

Please select any symptoms you are experiencing Do you have any support systems in place?