Prerequisite Questions

Why we need you to fill out this form

It is important for your safety and well-being that these questions are answered to determine if you can attend the Adamas Nexus meetings. All your answers are confidential.

Please check your ‘junk’ mailbox for our response and ongoing meeting details that will come from kay@adamasnexus.com

First Name

Last Name

1. Are you safe?

If not, please call 000 immediately and ask for police assistance.

2. Are you still in the abusive situation?

3. When was the abuse?

4. In regard to support services

There is a list of support services in the Resources tab on this website that you can access after submitting this questionnaire.

5. If you are using or have used support services, please name them.

6. Do you have a mental health plan?

If yes, please speak to your health professional before attending.

7. Are you seeing a psychologist, psychiatrist or counsellor?

If yes, please speak to your health professional before attending.

8. How did you hear about us?

9. If you said other in Question 8, please tell us how you heard about us

10. What format of meeting are you interested in attending?

11. Which state/territory do you live in?

Please register this information with Adamas Nexus