Mind Aftercare Form

In collaboration with the Victorian Department of Health, Mind Australia has been contracted to deliver the Aftercare suicide prevention program.

Aftercare provides short term intensive and structured support with a peer worker and counsellor to people in the LGBTIQASB+ community and their families (choice/origin) following a suicidal crisis.

Please complete this form so we have enough information to provide you with support.
You can see our data and privacy policy here.

Start Time

Completion Time

Name

I understand that by submitting this information, I am consenting to Mind Australia’s Aftercare contacting me by the phone number and/or email provided *

I understand that my information may be collected and notes will be recorded if I engage in support through Aftercare, in line with Mind’s Privacy, Confidentiality, and Consent policies. *

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Preferred First Name *

Preferred Last Name *

Date of Birth *

Phone number *

Email Address *

Current Residential Address *

Street address *

City *

State *

Postcode *

Pronouns *

How did you hear about our service? *

Self-described sexuality or sexual orientation

Self-described gender

Do you identify as transgender? *

YesNoUnsurePrefer not to answer

Were you born with a variation of sex characteristics (sometimes called intersex or differences of sex development)? *

YesNoUnsurePrefer not to answer

Note: There are many different innate variations of sex characteristics, some of which are associated with a medical diagnosis (e.g., Congenital Adrenal Hyperplasia, Androgen Insensitivity Syndrome, Klinefelter’s Syndrome, Turner Syndrome, Hypospadias, Mayer-Rokitansky-Küster-Hauser syndrome, etc.)

What is your ethnicity/ancestry? *

What country were you born in? *

Are you from a refugee or asylum seeker background? *

YesNoUnsurePrefer not to answer

Are there any other communities or cultures you are connected to that are important in your journey?

What language do you speak at home? *

Is an interpreter required/preferred? *

Other type of income *

Do you have any accessibility needs or things we should know that would facilitate your engagement with us?Eg. Telehealth only, AUSLAN interpreted sessions, meeting in areas with no steps, etc.

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We want to let you know that this page includes questions about suicide, suicidal thoughts, distress, and your mental health and wellbeing.

Some of these questions can feel personal or may bring up difficult feelings.Please take your time and share only what feels okay for you. You can skip any questions, pause, or come back later if you need to.

This information helps us understand how to support you in a way that feels safe, respectful and relevant to your needs.

Have you had thoughts or attempts to die by suicide in the last 12 months? *

YesNo

Are you currently experiencing/Have you experienced any of the following in the past 12 months?

Are you concerned about your substance or alcohol use?

YesNo

Please tell us more *

In the event of an emergency, who is the main person we can contact on your behalf? *

What is your emergency contact's contact number? Please provide telephone or mobile number *

Any additional safety person contacts details

Is there anything further we should know about these contacts, e.g. what to disclose/not disclose to them

Do you have any medical (non-psychiatric) conditions or disabilities you'd like us to know about?

Do you have a mental health diagnosis that you identify with and would like to disclose?

Are you on any medications that would be helpful for us to know about - and if so, how long have you been taking them?

What supports do you currently have in place?

What would you like to get out of your Aftercare journey?

Do you accept phone calls or would you like a text message before we call?

No - please send text message first before callingYes - phone calls are ok

Is there anything else you would like to share about who you are or add to the above information?