Assessment Form For AFOS- Group Consultation Assessment Form – Group Consultation SECTION 1: PERSONAL INFORMATION User Code (Sent to your email. Please do not include your name) * How old are you * Birthday Day Gender * Marital Status SECTION 2: TRAUMA HISTORY Tell us a bit about the traumatic experience * Current Symptoms Checklist (Please check all that applies to you) * Depressed Mood Excessive Worry Impulsivity Sleep Pattern Disturbance Loss of Interest Low Motivation Decreased Libido Concentration Problems/ Forgetfulness Change in Appetite Excessive Guilt Decreased need for sleep Crying Spells Increased Risky Behaviours Unable to Enjoy Activities Anxiety/ Panic Attacks Avoidance Increased Libido Racing Thoughts Suspiciousness Excessive Energy Increased Irritability Excessive Need for Sleep Fatigue None of the above Were these symptoms present before 1st June, 2022 * Not at allYes, just a littleYes, somewhatYes, most of themYes, all of them Have these symptoms increased since 1st June, 2022 * Not at allYes, just a littleYes, somewhatYes, most of themYes, all of them So far, what solutions have been helpful? * Have you experienced any previous trauma (e.g. serious accident, life threatening illness, sexual abuse, etc) * YesNoCan't Remember If yes, please specify the traumatic experience Have you struggled with any of these in the past (check all that applies) * Post Traumatic Stress Disorder Depression Anxiety Alcohol Abuse Other Substance Abuse (e.g. Marijuana, Tobacco) Schizophrenia Bipolar Affective Disorder Anger Management Suicide/ Suicidal Thoughts None of the above SECTION 3: PREFERENCES Would you like us to send you follow-up emails? (We don’t spam) * Yes No Follow-up emails help check in on your general well-being and provide proven psychological tips for the traumatic experience, stress management, relationships, etc. for a healthy work-life balance and well-being If yes, when is your most preferred time of the day? MorningsAfternoonsEveningsNight Time Would you like us to place follow-up calls? (We don’t spam) * Yes No Follow-up calls give you an avenue to express yourself to a trained phone helpline. We’ll notify you via email before placing a call. If yes, when is your most preferred time of the day? MorningsAfternoonsEveningsNight Time Would like to have one-on-one sessions (individual) Yes No Not sure Is there anything else you’ll like us to know? If you are human, leave this field blank. Submit Δ
