Online assessment

Let us find the right support for you

This helps us understand what is going on for you and match you with the right care. Answer as honestly as you can, in your own time. Dr Francis Katoa, a Pasifika GP, will review your answers, and if it is safe to support you online, we will book your telehealth consult, usually within 24 to 48 hours.

This is not an emergency service, and we cannot monitor this form in real time. If you need urgent help right now, free call or text 1737 any time to talk with a trained counsellor, or call 111 in an emergency.

First, a quick check

In the past 2 weeks, how often have you had thoughts that you would be better off not here, or of hurting yourself?

Not at all Some days More than half the days Nearly every day

Thank you for telling us. If you are not safe right now, please free call or text 1737 any time, or call 111. You do not have to wait for us to reach out. Please still finish and send this form so we can prioritise you, and reach out to someone you trust.

What are you reaching out about?

Choose what fits best

You can change this later, and you can tell us more in your own words on the next page.

ADHD, attention & focus

Trouble focusing, restlessness, organisation, or wondering about ADHD.

Anxiety & worry

Feeling nervous, on edge, panicky, or worrying you cannot switch off.

Depression & low mood

Feeling down, flat, hopeless, or losing interest in things.

After-baby (postpartum) mood

Mood, worry or coping since your baby arrived.

Stress, burnout & sleep

Feeling overwhelmed, exhausted, or struggling to rest.

Something else / not sure

Grief, trauma, relationships, anger, or you are not sure where to start.

Whatever you choose, a Pasifika clinician reviews everything. There are no wrong answers.

Do not fill this in:

1 About you and your aiga

Full name

Preferred name

Date of birth

Gender

NHI (if known)

Which Pasifika ethnicities do you identify with? (tick all that apply)

Samoan Tongan Cook Islands Māori Niuean Fijian Tokelauan Tuvaluan Kiribati Other

Languages spoken at home

Were you born in Aotearoa NZ?

Who lives in your household / aiga?

Work or study right now

Is faith or church part of your life? (optional)

In your aiga or community, how is it understood when someone struggles with focus, energy or mood?

Who do you usually turn to when things feel hard?

How much does worry about shame, judgement or fa'alavelave get in the way of asking for help?

2 What brings you here

In your own words, what is going on for you?

How long has this been going on?

What is hardest in your day to day?

What are you hoping to get from this assessment?

Have you ever been assessed or diagnosed with ADHD or anything else before?

3 Focus and attention right now

Over the past 6 months, how often have you experienced each of these? Choose the answer that fits best.

4 Attention and organisation

How often do these happen for you, as an adult? (If you are filling this in for a younger person, answer for them.)

5 Restlessness and impulsivity

How often do these happen for you?

6 When you were a child (before age 12)

ADHD starts in childhood, so this part matters. Answer as best you remember.

Were these focus or restlessness difficulties there when you were a child?

Yes, clearly Some No Not sure

What was school like for you? (reports, grades, behaviour, getting into trouble)

As a child, were you ever described as any of these? (tick all that apply)

A daydreamer Couldn't sit still Always in trouble "Lazy" or "not trying" Forgetful Very talkative Bright but distracted

Did you ever get learning support, get held back, or get stood down / suspended?

Who first noticed something was different?

7 Where it affects your life

How much difficulty do focus, organisation or restlessness cause in each area?

Give an example of how this has affected you recently.

8 Mood and worry

Over the past 2 weeks, how often have you been bothered by these?

9 Sleep, energy and substances

How is your sleep? (getting to sleep, staying asleep, racing mind)

Alcohol — how often and how much?

Cannabis, vaping, smoking or other?

Coffee or energy drinks per day?

Do you use anything to help you focus or settle?

10 Your safety

We ask everyone this. It helps us keep you safe.

Over the past 2 weeks, how often have you had thoughts that you would be better off not here, or of hurting yourself?

Not at all Some days More than half the days Nearly every day

Thank you for telling us. If you are not safe right now, please free call or text 1737 any time, or call 111. You do not have to wait for us to reach out. You can still finish and send this form, and we will prioritise you.

Anything you want us to know about your safety? (optional)

11 Health and development

Any medical conditions? (e.g. thyroid, epilepsy, head injury, hearing or vision)

Medications you take now

Allergies

Anything known about your pregnancy, birth or early development? (optional)

12 Your aiga's health

Does anyone in your aiga have any of these? (tick all that apply)

ADHD or attention difficulties Depression Anxiety Bipolar Addiction Learning difficulties

Anything else about your aiga you want to add?

13 Your strengths

What are you good at, or proud of?

What helps you focus or feel settled?

14 Your GP and consent

Your GP and clinic name

Best email or phone to reach you

Do we have your consent to liaise with your GP and send them a clinical note?

Yes No Ask me first

I understand this questionnaire helps Pasifika Rise assess whether telehealth support is right for me, and I consent to a clinician reviewing it.

Your answers are private and used only to arrange and guide your care. How we protect your information.

Do not fill this in:

1 About you and your aiga

Full name

Preferred name

Date of birth

Gender

NHI (if known)

Which Pasifika ethnicities do you identify with? (tick all that apply)

Samoan Tongan Cook Islands Māori Niuean Fijian Tokelauan Tuvaluan Kiribati Other

Languages spoken at home

Were you born in Aotearoa NZ?

Who lives in your household / aiga?

Work or study right now

Is faith or church part of your life? (optional)

In your aiga or community, how is it understood when someone struggles with their mood or wellbeing?

Who do you usually turn to when things feel hard?

How much does worry about shame, judgement or fa'alavelave get in the way of asking for help?

2 What brings you here

What would you like support with? (tick all that apply)

Anxiety or worry Depression or low mood After-baby (postpartum) mood Stress or burnout Sleep Grief or loss Trauma Anger Relationships Something else

In your own words, what is going on for you?

How long has this been going on?

What is hardest in your day to day?

What are you hoping to get from reaching out?

Have you been assessed, diagnosed or treated for your mental health before?

3 How you have been feeling

Over the past 2 weeks, how often have you been bothered by these?

3b Since your baby arrived

Only if this fits your situation. There are no wrong answers.

How old is your baby?

Have you been able to enjoy and laugh with your baby?

Who is helping you with the baby, and how supported do you feel?

4 Your safety

We ask everyone this. It helps us keep you safe.

Over the past 2 weeks, how often have you had thoughts that you would be better off not here, or of hurting yourself?

Not at all Some days More than half the days Nearly every day

Anything you want us to know about your safety? (optional)

5 Health and lifestyle

How is your sleep?

Any medical conditions? (e.g. thyroid, diabetes, pain, recent illness)

Medications you take now

Allergies

Alcohol — how often and how much?

Cannabis, vaping, smoking or other?

6 Your aiga's health

Does anyone in your aiga have any of these? (tick all that apply)

Depression Anxiety Bipolar ADHD Addiction Suicide or self-harm

Anything else about your aiga you want to add?

7 Your strengths

What are you good at, or proud of?

What helps you feel settled or get through a hard day?

8 Your GP and consent

Your GP and clinic name

Best email or phone to reach you

Do we have your consent to liaise with your GP and send them a clinical note?

Yes No Ask me first

I understand this questionnaire helps Pasifika Rise assess whether telehealth support is right for me, and I consent to a clinician reviewing it.

Your answers are private and used only to arrange and guide your care. How we protect your information.

Malo, thank you for trusting us with this.

Your questionnaire is on its way to Dr Francis Katoa for clinical review. We aim to be in touch within 24 to 48 hours to confirm whether telehealth support is right for you and book your consult. We are not able to monitor this form in real time or after hours, so if anything feels urgent before then, free call or text 1737 any time, or call 111 in an emergency.

That did not send

Something stopped your questionnaire from sending, so we have not received it yet. Please email admin@pasifikarise.co.nz to let us know, or press “Try again”. If anything feels urgent, free call or text 1737 any time, or call 111 in an emergency.