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Private 1:1 Stay, Client Assessment
Emergency contact — May Brett contact this person in an emergency?
Yes
No — please discuss with me
Safety — In the past month, have you wished you were dead, wished you would not wake up, or had thoughts of suicide?
No
Yes
Prefer to discuss directly
Safety — Are you having thoughts of suicide right now? This form is not monitored continuously. If you may act or cannot stay safe, seek local emergency help now.
No
Yes
Unsure — I need support
Care coordination — Would you be willing to discuss consent for Brett to coordinate with your doctor or treatment team?
Yes
I would like more information
No
House agreements — Are you willing to discuss and agree rules around substances, visitors, privacy and respectful behaviour?
Yes
I have questions to discuss
No
Consent — I agree that Brett Moran may review these responses, including sensitive health information, to discuss my support needs and suitability for a stay.
Acknowledgement — I understand this form is not monitored continuously, is not an emergency service or medical assessment, and does not confirm acceptance for a stay.
Declaration — The information I have provided is accurate to the best of my knowledge. I will discuss relevant changes before arrival.
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