Wellbeing Check Up

Please complete the following confidential Wellbeing Check Up to aid EAP Assist to promptly understand your difficulties & issues in order to provide you with immediate support & advice. Please answer each question with a Yes or No response. If you answer Yes, please then go on to provide further details by explaining your difficulties & issues. Once you complete this Check Up your EAP Assist counsellor will contact you by mobile and/or email (please advise preferred contact if any).

Wellbeing Check Up Form

Name (*)

Date of Birth (*)

Email Address (*)

Mobile

Employer's Name (*)

Employer’s Address

Employer’s EAP Helpline Number/Access Code

Do you suffer from depression Do you suffer from depression Yes No

Please explain:

Do you suffer from anxiety Do you suffer from anxiety Yes No

Please explain:

Do you suffer from stress Do you suffer from stress Yes No

Please explain:

Do you have difficulty with diet Do you have difficulty with diet Yes No

Please explain:

Do you have difficulty with exercise Do you have difficulty with exercise Yes No

Please explain:

Do you have difficulty with alcohol Do you have difficulty with alcohol Yes No

Please explain:

Do you have difficulties with anger Do you have difficulties with anger Yes No

Please explain:

Do you have difficulties with relationships Do you have difficulties with relationships Yes No

Please explain:

Do you have thoughts of self-harming Do you have thoughts of self-harming Yes No

Please explain:

Do you have financial difficulties Do you have financial difficulties Yes No

Please explain:

Do you suffer from domestic violence Do you suffer from domestic violence Yes No

Please explain:

Do you have difficulties with your sexuality Do you have difficulties with your sexuality Yes No

Please explain:

Do you have difficulties with drugs Do you have difficulties with drugs Yes No

Please explain:

Do you have issues with body image Do you have issues with body image Yes No

Please explain:

Do you suffer from grief Do you suffer from grief Yes No

Please explain:

Do you have difficulties with sleep Do you have difficulties with sleep Yes No

Please explain:

Do you have difficulties with cigarettes Do you have difficulties with cigarettes Yes No

Please explain:

Do you have parenting concerns Do you have parenting concerns Yes No

Please explain:

Do you have issues with gambling Do you have issues with gambling Yes No

Please explain:

Do you suffer from traumatic experiences Do you suffer from traumatic experiences Yes No

Please explain:

Do you have difficulties at work Do you have difficulties at work Yes No

Please explain:

Do you suffer from burnout Do you suffer from burnout Yes No

Please explain:

Do you experience bullying Do you experience bullying Yes No

Please explain:

Do you suffer from any other issues not listed above Do you suffer from any other issues not listed above Yes No

Please explain:

Describe what support & advice you would like from EAP Assist: Describe what support & advice you would like from EAP Assist: Yes No

Please explain: