PEER MENTORING PROGRAM PARTICIPANT REGISTRATION

Please note all your information is kept private and confidential.

Thank you for applying for the Peer Mentoring Program.

Please answer all questions below truthfully and accurately, if you have any questions feel free to contact Rachael Duck on (03) 9994 0354 ext 214 or send her an email with subject Peer Mentoring Program at Rachael.duck@eatingdisorders.org.au.

Please have the following information with you before starting this registration form:

The contact details (including phone and email) for your GP, mental health clinician and personal support person

Keep in mind that:

All fields marked with an asterisk (*) on the application are required.
You must click the 'Submit' button at the end to send your application to our PMP team for consideration.

At this time, you have to finish the application in one sitting. If you leave the form idle for more than 20 minutes, your session will expire, and you will have to start over!

Here at EDV, we are always trying to make things easier for our community, this form is new and we are still working out some tech things! If you are having troubles submitting this form, please contact Andrew on andrew.synnot@eatingdisorders.org.au or 9994 0354 ext 227 and he can help you out (please note Andrew works Tuesday-Friday).

Referral Information

I am referring

I am referring (If Other)

Clinicians First Name

Clinicians Last Name

Clinicians Email

Clinicians Organisation

Clinicians Role

Clinicians Phone

Please make sure to only use numbers (no spaces or special characters)!

Please note: once you have submitted this form, a confirmation email will be sent to the client only. You can contact Rachael from EDV on
(03) 9994 0354 ext 214 or send her an email with subject Peer Mentoring Program at Rachael.duck@eatingdisorders.org.au.

Basic Information

The rest of the information relates to the client you are referring.

First Name

Last Name

Date of Birth

Phone

Please make sure to only use numbers (no spaces or special characters)!

Email

Address Information

Street

City

Postcode

State

Country Of Birth

Employment Status

Highest Education Level

Identification

I identify as

I identify as (if not listed)

Preferred Pronouns

Eating Disorder Diagnosis

Current Primary Eating Disorder Diagnosis

If OSFED, please expand

Current Secondary Disorder Diagnosis

If OSFED, please expand

Do you have any other mental health conditions (previous or current?)

Recent Treatment
This program is primarily for adults with an eating disorder leaving hospital or an intensive day program.

Have you had treatment for your eating disorder within the last 6 months?

What has been the treatment you have received?

Where have you received this treatment? (e.g. BETRS day program)

Eating Disorder History

Please answer the below in numerical form.

What age were you when you were diagnosed with the eating disorder?

How long have you had the eating disorder for?

Years

Months

What behaviours, thoughts and feelings do you have that are related to the eating disorder? What do you think brought it on? What has made the eating disorder last as long as it has?

History of Medical and Psychiatric Treatment

Have you had medical or psychiatric admissions for an eating disorder?

How many admissions?

What were these admissions and how long, if you can remember.

Have you had other outpatient treatment or participated in day programs before?

Have you (or do you currently) access therapy (public or private)?

History of Engagement with Treatment Services

Have you been able to comply with the requirements of treatment?

What has worked well for you in treatment?

What hasn't worked so well for you in treatment?

Overall, how would you describe your experience of treatment?

History of Risk

Do you find that you struggle with thoughts of suicide?

Have you ever attempted suicide? (if so, when was this?)

Have you ever self-harmed or had thoughts of wanting to self harm?

Any current risks?

Medical Information

Are there any current medical concerns?

If yes, what are the details?

Have you (or do you currently) take any medications?

Support Action Plan

Ongoing and regular engagement in treatment is a condition of participation in the program.

Please note that engagement in PMP requires you to provide 3 support contacts and consent for EDV to share and receive information about you with these nominated people. These support contacts will be informed of your involvement in the program and will be contacted should risk be identified.

If these supports change, the participants must update EDV as soon as possible.

GP / Primary Treating Clinician

First Name

Last Name

Service / Organisation

Phone

Please make sure to only use numbers (no spaces or special characters)!

Email

Address Information

Street

Postcode

City

State

Notes / Information about this person

Authorisation of Sharing & Receiving Information

I authorise EDV staff to share and receive detailed information about me with the above person.

Mental Health Practitioner (e.g. psychiatrist, psychologist, counsellor, clinical mental health social worker)

First Name

Last Name

Service / Organisation

Phone

Please make sure to only use numbers (no spaces or special characters)!

Email

Address Information

Street

Postcode

City

State

Notes / Information about this person

Authorisation of Sharing & Receiving Information

I authorise EDV staff to share and receive detailed information about me with the above person.

Personal Support (Family / Friend / Colleague)

First Name

Last Name

Email

Phone

Please make sure to only use numbers (no spaces or special characters)!

Address Information

Street

Postcode

City

State

Notes / Information about this person

Authorisation of Sharing & Receiving Information

I authorise EDV staff to share and receive detailed information about me with the above person.

Matching Information: Tell us a little bit about you
Details provided in this section will help to guide the matching process along with other organisational considerations.

Why do you want to participate in the Peer Mentoring Program?

What does a Peer Mentor need to understand about you or your current values and goals? Think about whether you want to work with someone who's similar or different to you. What kind of things or people inspire, encourage and motivate you to continue in your recovery?

Tell us a little about your interests and likes?

I would prefer to be matched with someone who is...

Age

How important is this to you?

Gender

How important is this to you?

Eating Disorder History

How important is this to you?

Location

How important is this to you?

What days and times are you available to meet with your Mentor?

Acknowledgement

In submitting this form, I have to the best of my knowledge provided information that is true and correct and I am agreeing to be a participant in the Peer Mentoring Program.

Here at EDV, we are always trying to make things easier for our community, this form is new and we are still working out some tech things! If you are having troubles submitting this form, please contact Andrew on andrew.synnot@eatingdisorders.org.au or 9994 0354 ext 227 and he can help you out (please note Andrew works Tuesday-Friday).

PEER MENTORING PROGRAM PARTICIPANT REGISTRATION

Matching Information: Tell us a little bit about youDetails provided in this section will help to guide the matching process along with other organisational considerations.

Matching Information: Tell us a little bit about you
Details provided in this section will help to guide the matching process along with other organisational considerations.