SADFA Military Veteran Needs Assessment - Emmet Counselling and Coaching

First Name

Last Name

Phone/Mobile

1. During which years did participate in Military Service (Multiselect Dropdown)

Other:

2. In which Military Operations did you participate?

3. I was exposed to the following:

Bush War (Operational Exposure)

Township Exposure

Not Applicable

Other:

4. I experienced the following trauma:

Other:

Safety

5a. What do you think about regularly?

5b. Are these thoughts normal and rational:

Yes

5c. Do you think about harming anybody?

Yes

5d. Do you think about giving away your belongings?

Yes

5e. Are you considering moving away and starting somewhere new?

Yes

5f. Are your thoughts very negative?

Yes

5g. Are you considering suicide?

Yes

5h. Do you have hope for the future?

Yes

5i. Do you have a history of mental health issues such as depression?

Yes

5j. Are you involved in any coaching, counselling, or psychiatric support?

Yes

5k. For how long have you been receiving coaching, counselling, or psychiatric support?

Yes

5l. Do you think you need counselling?

Yes

5m. Are you experiencing a crisis now?

Yes

5n. If you answered yes in question above. What crisis are you experiencing?

5o. Are you experiencing trauma now?

Yes

5p. If you answered yes in question above. What trauma are you experiencing?

5q. Are you willing to become part of a group support process?

Yes

5r. Do you have a place where you feel safe and where you can retreat to meditate or pray?

Yes

5s. Are you willing to work out a personal development plan?

Yes

Belonging

6a. Do you have social support (social engagement) from your family, friends, colleagues or a church support group?

Yes

6b. Are you involved in leisure activities such as sport and other social activities to relax from the stress of life?

Yes

6c. Are you concerned about your relationships with a spouse or partner, their children, any other family members, friends or colleagues?

Yes

6d. Are you concerned about your social activities and use of social media as part of escaping from reality

Yes

Livelihood

7a. Do you have enough food?

Yes

7b. Do you have enough support to your physical needs such as clothing and bedding?

Yes

7c. Do you have a safe home and are you sleeping well?

Yes

7d. Are you still following your normal routine?

Yes

7e. Do you have transport?

Yes

7f. Are you healthy or experiencing alarming physical symptoms?

Yes

7g. Do you need any medical support?

Yes

7h. If you answered yes in question above. What medical support do you need?

7i. Are you taking any chronic medicine?

Yes

7j. If you answered yes in question above. What chronic medicine do you use?

7k. Are you still working?

Yes

7l. Do you have your own business?

Yes

7m. Do you have an income?

Yes

7n. Are you concerned about your working conditions?

Yes

7o. Do you have any financial need?

Yes

7p. Are you concerned about providing for your children or any other family member?

Yes

7q. Are you concerned about loss or change of physical abilities or eating habits (eating too little or too much)

Yes

7r. Are you concerned about an increase in use of chemical or addictive substances or alcoholic beverages?

Yes

7s. How many times per week do you use chemical or addictive substances or alcoholic beverages

None

1 to 3

4 to 10

11 to 20

More than 20

Other:

Emotional

8a. Are you concerned about your state of mind?

Yes

8b. Are you experiencing a loss of interest or zest for life or a feeling that you are not in touch with reality?

Yes

8c. Are you feeling anxious and distressed?

Yes

8d. Are you willing to speak about your emotions?

Yes

8e. Are you feeling sad and emotionally unstable?

Yes

8f. Are you feeling depressed most of the time and don’t have any good or positive days?

Yes

8g. Are you experiencing feelings of inferiority or being a burden to others?

Yes

8h. Do you talk to someone about your feelings and/or strange emotions you might experience?

Yes

8i. Do you isolate yourself?

Yes

8j. Do you experience feelings of guilt?

Yes

8k. Do you experience feelings of anger?

Yes

Spiritual

9a. Do you have any spiritual support from a small group, family, friends or religious leader that you trust?

Yes

9b. Do you need prayer?

Yes

9c. What do you think you need prayer for?

9d. How is your relationship with God?

Very Good

Good

Average

Not Good

9e. Do you feel connected to God now?

Yes

9f. Do you feel angry with God or disappointed in Him?

Yes

9g. Are you experiencing conflict between your beliefs and what happened to you?

Yes

10. Is there anything else you would like to add?