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Session Consent Form

WellTogether101 Support Group

About this session: This session runs for 90 minutes total — comprising 45 minutes of Focused Psychological Strategies (FPS) and 45 minutes of group connection and peer support. Medicare is bulk billed for the FPS component (minimum 40 minutes, item 2727).

👤 Your Details

First Name (as per Medicare) *

Last Name (as per Medicare) *

Date of Birth *

Phone Number

Email Address

Session Date *

Date of Signing *

🏥 Medicare Consent

Do you have a Medicare Card? *

🌿 Why Are You Here Today?

Tick all that apply

I am attending today to learn how to better manage symptoms of stress, anxiety or low mood, and to develop skills in mindfulness, CBT, relaxation strategies and positive psychology for my health and wellbeing.

✨ WHO-5 Wellbeing Index

Over the past two weeks, how often have you felt the following?

1. I have felt cheerful and in good spirits

2. I have felt calm and relaxed

3. I have felt active and vigorous

4. I woke up feeling fresh and rested

5. My daily life has been filled with things that interest me

💬 Quick Questions

Is this your first time attending a WellTogether101 session?

Would you be interested in becoming a peer facilitator in the future?

Facilitated by Dr Jennifer Yuan — WellTogether101 Foundation Ltd (ACN 697 159 425)