AMITY HEALTH MENTAL HEALTH PORTAL – WHEATBELT

This free service is available to any individual:

  1. Experiencing a mild to moderate mental health issue OR a severe and persistent mental

health illness but currently NOT in crisis or in need of urgent assistance

  1. Experiencing financial hardship
  2. Living in an area where alternative mental health services are not available (such as Better Access).

IF YOUR CLIENT IS PRESENTING IN AN ACUTE PSYCHIATRIC CRISIS OR IF RISK IS HIGH, PLEASE CALL YOUR LOCAL AREA MENTAL HEALTH SERVICE (WACHS)

Client Details
Surname: / First Name:
Home Phone:
Mobile No: / Medicare No:
D.O.B: / Gender:
Address: (If physical address is different from Postal address please supply both)
Preferred Email:
Language spoken: / Interpreter required: Yes  / No 
Aboriginal  Torres Strait Islander  Both Aboriginal and Torres Strait Islander  CALD 
Prior Mental Health Care: Yes  No 
Mental Health Issue
Referrer Details
Name: / Date of referral:
Practice/Organisation: / Ph:
Email: / Fax:
Address:
Consent for referral or Parent Consent signature:

The Kessler – 10LM (K-10+)

Name: ______Date Completed:____/____/______

Instructions:
The following ten questions ask about how you have been feeling in the last four weeks. For each question circlethe number under the option that best describes the amount of time you felt that way.
None of the time / A little of the time / Some of the time / Most of the time / All of the time
  1. In the last four weeks, about how often did you feel tired out for no good reason?
/ 1 / 2 / 3 / 4 / 5
  1. In the last four weeks, about how often did you feel nervous?
/ 1 / 2 / 3 / 4 / 5
  1. In the last four weeks, about how often did you feel so nervous that nothing could calm you down?
/ 1 / 2 / 3 / 4 / 5
  1. In the last four weeks, about how often did you feel hopeless?
/ 1 / 2 / 3 / 4 / 5
  1. In the last four weeks, about how often did you feel restless or fidgety?
/ 1 / 2 / 3 / 4 / 5
  1. In the last four weeks, about how often did you feel so restless you could not sit still?
/ 1 / 2 / 3 / 4 / 5
  1. In the last four weeks, about how often did you feel depressed?
/ 1 / 2 / 3 / 4 / 5
  1. In the last four weeks, about how often did you feel that everything was an effort?
/ 1 / 2 / 3 / 4 / 5
  1. In the last four weeks, about how often did you feel so sad that nothing could cheer you up?
/ 1 / 2 / 3 / 4 / 5
  1. In the last four weeks, about how often did you feel worthless?
/ 1 / 2 / 3 / 4 / 5
The next few questions are about how these feelings may have affected you in the last four weeks. You need not answer these questions if you answered ‘None of the time’ to all of the previous ten questions about your feelings.
  1. In the last four weeks, how many days were you TOTALLY UNABLE to work, study or manage your day to day activities because of these feelings?
/ __(Number of days)
  1. (Aside from those day), in the last four weeks, HOW MANY DAYS were you able to work or study or manage your day to day activities, but had to CUT DOWN on what you did because of these feelings?
/ __(Number of days)
  1. In the last four weeks, how many times have you seen a doctor or any health professional about these feelings?
/ __(Number of days)
  1. In the last four weeks, how often have physical health problems been the main cause of these feelings?
None of the time
A little of the time
Some of the time
Most of the time
All of the time / 




K10 Score
10 – 15
16 – 21
22 – 29
30 – 50 / Level of psychological distress
Low
Moderate level of psychological distress
High level of psychological distress
Very high level of psychological distress / SCORE
______/ 50

Please fax to: 9842 2798 Enquiries to: 9842 2797

Amity Health acknowledges WA Primary Health Alliance (WAPHA) for providing funding in its role as the operator of the Country WA PHN.