Urgent Mental Health Support Line Report
Call Type
*
Wellbeing Check
Crisis Call
Wellbeing Call
Admin
Hang up
Other
Safety Issues
*
Yes
None Identified
University Security Alerted
Emergency services were contacted
Call Terminated Unexpectedly
Yes
Does the Crisis Supporter recommend that the University contact the student?
*
Yes
The student knows how to book a counselling appointment if required
University decision
Start Date/Time
*
Please ensure you correctly select AM or PM.
Finish Date/Time
*
Please ensure you correctly select AM or PM.
Method of Contact
*
Phone
SMS
SMS then switched to Phone
Call Supporter
*
Incoming Number
*
If number is hidden or otherwise unavailable, note that in TEXT box above
Caller Name (please clarify if possible)
*
If unable to get a name, please note that in the TEXT box above
Student Number - Format should be s + 7 digits
*
If unable to get a number, please note that in TEXT box above
Which pronouns does the caller prefer to use?
*
he/him/his
she/her/her
they/them/theirs
Other
Did not ask
Is the caller living on campus?
*
Yes
No
Unknown
Is the student calling from overseas?
*
Yes
No
Unknown
Call Record Notes - All fields are Mandatory
Caller's issues regarding THEMSELVES (you may enter more than one item but no more than three)
*
Abuse and Trauma
Anxiety
Family and Relationships
Domestic and Family Violence
University studies
Depression
Suicidality
Loneliness or Isolation
Bereavement and Loss
Substance Abuse
Carer Issues
Health and Disability
Practical Help
Employment
Financial Management
Self - only to be used if no other categories apply
Behaviour
Community Disaster
Caller's issues regarding OTHERS (you may enter more than one item but no more than three)
Abuse and Trauma
Family and Relationships
Domestic and Family Violence
Community Disaster
Employment
University studies
Substance Abuse
Depression
Bereavement and Loss
Carer Issues
Health and Disability
Practical Help
Loneliness or Isolation
Financial Management
Anxiety
Suicidality
Behaviour
Other
Session Notes
*
Referrals
University Referral
External Referral
Other
University Referrals
Counselling Team
Administration
Student Services
Crisis Line
Website
Complaints
Student Advocacy
Health Services
Disability, Equity, and Inclusion
Security
Lecturer
Course Coordinator
Learning Support
IT support
International Support
Careers Advice
External Referrals
GP
Hospital
Lifeline
Beyond Blue
Police
000 – Emergency Services
Health Direct
Sexual Assault Advice
Suicide Call Back
Psychologist
Psychiatrist
1800 Respect
Relationships Australia
Headspace
Grief Line
Kids Helpline
Mental Health Line
Parent Line
Legal Aid
Other Referral
Suicide and Self-harm
Is the caller experiencing any suicidal ideation?
*
Yes
No
Did not ask
Is the caller considering suicide?
*
Yes
No
Did not ask
Does the caller have a suicide plan?
Yes
No
Did not ask
Do they have means?
Yes
No
Did not ask
Does the caller intend to act on their plan?
Yes
No
Did not ask
Is there evidence that there is imminent risk?
Yes
No
Has the caller currently or recently self-harmed?
*
Yes
No
Did not ask
Other Risks
Is there any indication that there has been a crime?
Yes
No
Is there an indication that there is family violence?
Yes
No
Is there an indication of any child protection issues (either by or against them)?
Yes
No
Is there an indication of any other emergency or safety concerns?
Yes
No
Protective Factors
If risk is present - are there any protective factors?
Risk Assessment/Outcome
Is the caller at risk?
*
Yes
No
Description of risk
Details of Safety Plan if one is agreed
If this call relates to a Wellbeing Check request, have all risks flagged in the referral been addressed?
*
Yes
No
Not a Wellbeing Check
Have you confirmed the call that relates to this form as being from one of these RMIT numbers?
*
1300 305 737
0488 884 162
Confirmed via Wellbeing Check Request Form/Email from RMIT
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