Online via Zoom

CARER INITIAL CONTACT FORM

Estimated completion time is 10-15 minutes.

Hello, this will be your first step in engaging with Eating Disorders QLD (EDQ). We acknowledge that it can be difficult to discuss your experiences of caring for a loved one with an eating disorder and body image issues.

To make it a bit easier, we have developed this form you can complete and send back to us.

Once this form is completed, one of our Carer & Key Support Coaches will contact you to discuss the next steps in the process of engaging with EDQ.

Looking forward to meeting you.

Terms & Conditions

Please note, your loved one with an eating disorder does not need a formal diagnosis and can be any age for you as the carer to access our supports.

EDQ Cancellation Policy:

• EDQ requires 48 working hours’ notice of cancellation for all appointments

• In the event of 3 late cancellations or no-shows, your practitioner will discuss other support options with you before booking another appointment

We will email you a written Consent and Rights & Responsibilities Form for you to review and sign before your Intake Appointment. These documents detail how we handle your information. If you have any queries, feel free to ask any staff member.

I understand that the information I provide on this form will be stored on a secure database and shared within the EDQ team, as necessary.

To determine eligibility for EDQ’s funded services, are you a QLD resident?

Yes No

Please note, your loved one with an eating disorder does not need a formal diagnosis and can be any age for you as the carer to access our supports.

EDQ Cancellation Policy:

• EDQ requires 48 working hours’ notice of cancellation for all appointments

• In the event of 3 late cancellations or no-shows, your practitioner will discuss other support options with you before booking another appointment

We will email you a written Consent and Rights & Responsibilities Form for you to review and sign before your Intake Appointment. These documents detail how we handle your information. If you have any queries, feel free to ask any staff member.

Consent to Evaluation, Research and Reports/Publications:

EDQ may use client data collected to undertake program evaluations of EDQ services for the purpose of maintaining standards or identifying areas for improvement, as well as to report program outcomes to funding bodies or public forums (e.g. conferences or published papers/reports). Client data that may be used for this purpose can include demographic information, outcome, client feedback and group participation data. Any data analysed for this purpose will be de-identified and will only ever be published in a non-identifiable or aggregate form. I consent to my client data being used for evaluation and research purposes and understand that the outcomes of evaluation and research may be published in places that are accessible to the public. I understand that if I do not consent to my client data being used for evaluation and research purposes, it still may be used for mandatory reporting of service delivery to funding bodies. I understand that I can modify my consent to evaluation and research at any time. I understand that if I modify my consent, any previous reports/publications may not be able to be modified.

Yes No I would like to discuss this further during my intake

Date

Title

Family Name

Given Name(s)

Preferred Name

How would you describe your gender?

Male Female Other

If Other, please specify gender

Pronouns

Date of birth

Phone Number

Email

Relationship to loved one with an eating disorder

Age of loved one with an eating disorder:

Current Address

Suburb

Postcode

What is your proficiency in English?

Do you require an Interpreter/Auslan Connections and/or advocacy service?

No Yes

If Yes, please specify language

Do you need the use of assistive technology?

No Yes

If Yes, please specify technology

Do you have any current literacy/reading issues that you might need assistance with?

No Yes

Are you a current NDIS participant?

No Yes

Country of birth

Are you of Aboriginal or Torres Strait Islander Origin?

No Yes, Aboriginal Yes, Torres Strait Islander Yes, both Aboriginal and Torres Strait Islander

What cultural background or ethnicity do you identify with?

What is the main language spoken in your home?

Do you identify with the LGBTIQAP+ community?

Yes No Prefer not to answer

If Other, please specify status

What is your main source of income?

Disability Support Pension Other pension or benefit (please specify) Paid employment Compensation payments Other, e.g., superannuation, investments (please specify) No source of income

If Other, please specify source

In approximately which year did you first notice your loved one experiencing any eating disorder symptoms, including significant concerns about weight and shape?

If Other, please specify diagnoses

Which EDQ services are you interested in?

How did you hear about EDQ?

EDQ strives to be inclusive of diverse groups (Aboriginal and Torres Strait Islander peoples, Culturally and Linguistically Diverse (CALD), religious / spiritual beliefs, gender, sexual orientation, physical and intellectual disability, age and socio-economic status), that access the service. Please let us know if you have any requirements related to this statement, or would like to be given information on other available services that you could also connect with?

Is there anything else you would like EDQ staff to be aware of when contacting you?