Wellbeing Check Up

Wellbeing Check Up – Confidential EAP Support

Please complete the following confidential Wellbeing Check Up to aid EAP Assist to understand your difficulties & issues in order to provide you with some initial 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 completed you will be contact you by email.

Wellbeing Check Up Form

Please answer Yes or No. If Yes, provide details.
All responses are confidential and reviewed by qualified Australian counsellors.

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:

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Wellbeing Check Up

Wellbeing Check Up – Confidential EAP Support

Wellbeing Check Up Form