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First Step

Welcome to the First Step Client Registration Form

  • Please complete as much of this form as you can.
  • The only things you must complete are marked with a red *
  • If you have any questions or need assistance then please let reception know and we’ll help you out 🙂
Aboriginal and/or Torres Strait Islander *
Marital Status

Your Current Address

Contact details

Medicare details

The number next to your name

Veterans Affairs

Are you a Veteran? *

Pension/Health Care Card Entitlement Number

Do you have a…

Next of Kin

Please enter their full name

Emergency Contact

I don’t have any emergency contact

Same as next of kin?
Please enter their full name

Miscellaneous

Do you have a regular GP? *
Have you been referred by another service? *
Do you have an NDIS package? *
(inc. admissions & attendances to ED)
(inc. any time spent being held in police custody, in cells, on remand or custodial sentences)

Please read the following information in our privacy authority collection statement.

Once you have read and understood the contents, please sign to let us know you are ok with them.

If you have any questions or would like any part of this explained further, please just ask at reception 🙂

You are a client of First Step. You have asked us to provide you with medical and other health care services to assist you with your treatment and rehabilitation. To do this, we need to collect information from you and about you, which we will use to assess, diagnose, and treat your illness and for other limited purposes relating to quality control and management of First Step, administration of First Step, and billing including compliance with Medicare and Health Insurance Commission requirements.

We may need to disclose or discuss your health information with persons or bodies that we deal with to assist with your treatment or rehabilitation. This may be required in discussions with external doctors or health care providers, or in the ordering of medical tests and receipt of medical reports and medical results. If First Step needs to collect or release information in your health’s interest then you will be requested to sign a separate authority to authorise this request, if your treating Doctor at First Step feels that you are not sufficiently capable of signing this request then your treating Doctor will request or release such documents in the interest of your best health care. We may also be required to disclose your health information to other third-party providers if required by law, therefore if First Step is subpoenaed, receives a court order or search warrant then we are at liberty to release this information if the request in is writing from the relevant authority and a copy is held on file. Your medical records are stored on our medical database “Medical Director” which is backed up daily from our sever.

At First Step, we operate a multi-disciplinary practice with the First Step Legal Service. At some stage, you may seek advice from our First Step Legal Service. If you do, we will not disclose your health information to legal practitioners of the First Step Legal Service without your consent. If we consider that a disclosure of your health information will be beneficial either for your treatment or rehabilitation, or if the First Step Legal Service considers that the disclosure will be useful for its provision of legal advice or representation, we will ask you to complete a consent form permitting the disclosure.

If you are accessing treatment through First Step which will require the formulation of a GP Management Plan Medicare Item Number 721, Team Care Arrangement Medicare Item Number 723, GP Mental Health Treatment Plan Medicare Item Number 2700, 2701, 2715, 2717 or a GP Mental Health Treatment Plan review 2712, then by signing this document you agree to First Step preparing these plans on your behalf.

It may be necessary at some stage during your treatment for our clinical team to conduct a multi/disciplinary case conference with members of your treating team under Medicare Items Numbers 735, 739, 743. 747, 750 or 758 this conference will be initiated and conducted by your treatment medical practitioner.

Your medical file is the property of First Step. You have the right to access your file, however, under the Health Records Act 2001 (Vic), there may be situations where we are entitled to refuse access. All requests for the release of a medical file will be required in writing and will be considered individually.

You may review and withdraw any consent that you sign at any time.

First Step Policies and Procedures relating to privacy and confidentiality can be found at www.firststep.org.au/privacy.

Client’s Acknowledgement

I have read and understood the contents of this privacy authority collection statement.

Sign here

Your browser does not support e-Signature field.

Please complete the following sections as best as you can to help us understand you and your needs.

  • Tick the boxes that best describe your situation
  • Don’t worry if you cannot complete all the questions
  • Your worker will go over everything with you.

If you prefer not to complete it at all, that’s OK too, you can just skip by clicking Next at the bottom.

SECTION 1: SUBSTANCE USE

In the past four weeks (28 days) have you used any of the following substances? If yes, record number of days and how much you used in the past four weeks.

Nicotine products (ie. cigarettes or vapes)
1 – 28 days
Amount
Prescribed sedatives or sleeping pills (e.g. benzodiazepines, xanax, valium, serapax, rohypnol, stilnox etc.)
1 – 28 days
Amount
Prescribed Opioids (e.g. methadone/buprenorphine)
1 – 28 days
Amount
Alcohol
1 – 28
Amount
Illicit drugs
Cannabis (e.g. marijuana, pot, grass, hash, synthetic cannabis etc.)
1 -28
Amount
Methamphetamine (e.g., ice, speed, base)
1 – 28 days
Amount
Other amphetamine type stimulants (e.g. MDMA /ecstasy, diet pills etc.)
1 – 28 days
Amount
Non-prescribed benzodiazepines
1 – 28 days
Amount
Non-prescribed Opioids (e.g. heroin, codeine, methadone, oxycodone, morphine, fentanyl etc.)
1 – 28 days
Amount
Cocaine
1 – 28 days
Amount
Inhalants (e.g. nitrous, glue, petrol, paint thinner, Amyl etc.)
1 – 28 days
Amount
Hallucinogens (e.g. LSD, acid, mushrooms, PCP, ketamine, synthetic hallucinogens etc.)
1 – 28 days
Amount
GHB
1 – 28 days
Amount
Other substances (e.g. steroids caffeine/energy drinks, new and emerging drugs etc.)
1 – 28 days
Amount
Have you injected drugs in the past four weeks?
Did you inject with equipment used by someone else?

SECTION 2: HEALTH AND WELLBEING

What's your employment status?

In the past four weeks:

Have you been homeless?
Have you been attended to by an ambulance or been in hospital?
Have you been violent (incl. family violence) towards someone?
Has anyone been violent (incl. family violence) towards you?
e.g. anxiety, depression and problem emotions and feelings
e.g. extent of physical symptoms and bothered by illness
e.g. ablity to enjoy life, get on well with family and partner, satisfied with living conditions

SECTION 3: ALCOHOL USE (AUDIT)

The following questions will give us a picture of your recent alcohol use, and will help us determine how best to help you. Please select the response to each question that best describes your drinking. If you haven’t been drinking alcohol you don’t need to answer the questions.

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Have you drunk any alcohol in the last year?
How often do you have a drink containing alcohol?
How many drinks containing alcohol do you have on a typical day when you are drinking?
How often do you have six or more drinks on one occasion?
How often during the last year have you found that you were not able to stop drinking once you had started?
How often during the last year have you failed to do what was expected of you because of drinking?
How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session?
How often during the last year have you had a feeling of guilt or remorse after drinking?
How often during the last year have you been unable to remember what happened the night before because of your drinking?
Have you or someone else been injured because of your drinking?
Has a relative, friend, doctor, or other health care worker been concerned about your drinking or suggested you cut down?

SECTION 4: USE OF DRUGS OTHER THAN ALCOHOL (DUDIT)

The next questions will help us to understand whether use of all drugs other than alcohol is a problem for you. This includes illicit drugs & pharmaceutical medications (e.g. sleeping pills, pain killers). It does not include medication that you take as prescribed by your doctor. Please select the response to each question that best describes your use of all drugs (other than alcohol). If you haven’t been using any, then you don’t need to answer the questions.

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Have you used drugs other than alcohol in the last year?
How often do you use drugs other than alcohol?
How often do you use more than one drug on the same occasion?
How many times do you take drugs on a typical day when you use drugs?
How often are you influenced heavily by drugs?
Over the past year, have you felt your longing for drugs was so strong that you could not resist it?
Has it happened, over the past year, that you have not been able to stop taking drugs once you started?
How often over the past year have you taken drugs and then neglected to do something you should have done?
How often over the past year have you needed to take a drug the morning after heavy drug use the day before?
How often over the past year have you had guilt feelings or a bad conscience because you used drugs?
Have you or anyone else been hurt (mentally or physically) because you used drugs?
Has a relative or a friend, a doctor or a nurse, or anyone else been worried about your drug use or said to you that you should stop using drugs?

SECTION 5: LEGAL NEEDS ASSESSMENT

This section relates to legal needs that we may be able to assist you with. If you want to skip you can.

Are you currently receiving support or representation from a lawyer?

Safety

Does anyone around you make you feel unsafe or threatened? Is there anyone you feel you need protection from?
Do you have any current Family Violence or Personal Safety Intervention Orders? (for example, ex-partner, family members)?

Money

Do you owe anyone money? This could include organisations, the government, the bank or another person.
Do you have payments due or unpaid accounts?
Do you have unpaid fines?
Are you receiving the right Centrelink benefits?

Courts and Crime

Have you got any criminal charges or upcoming court dates?
Have you been contacted by police?
Do you have any paperwork asking you to attend court?
Do you have outstanding Warrants?

Housing

Have you had recent issues with a rental property?
Have you recently received a notice from your agent/landlord or been evicted recently?
Have you had trouble getting your bond returned?
Do you have an upcoming VCAT hearing?
Did you leave belongings behind at recent accommodation?
Do you have unpaid rent?
Are you on tenancy blacklists?

Family

Do you have any issues as a result of separating from a partner?
Issues resulting from Divorce or separation?
Are Child Protection involved?
Written agreements or orders about parenting arrangements?
Child support or paternity?

SECTION 6: PAST 30 DAYS (K10)… the final section 🙂

The following questions ask about how you have been feeling during the past 30 days. It’s important to understand how you are feeling and where you are at. For each question, select the response that best describes how often you had this feeling.

… tired for no reason?
… nervous?
… so nervous that nothing could calm you down?
… hopeless?
… restless or fidgety?
… so restless that you could not sit still?
… depressed?
… so depressed that nothing could cheer you up?
… worthless?