1. First Name
2. Last Name
3. Date of Birth
4. What is the participant's gender?
5. Does the participant currently reside in Australia?
6. Does the participant reside in Metropolitan Melbourne?
7. Does the participant have access to a computer or tablet with internet connectivity? Or is someone able to provide this access for them?
Note: Please note that HBH is an online study, with limited capacity for in-person assessments.
8. What is their primary language? (Please select)
Note: Primary language refers to the language they will be able to complete an assessment in.
9. Is the participant currently experiencing symptoms of any of the following health conditions that require treatment?
- Alcohol use disorder
- Substance use disorder
- Untreated mental health condition (e.g., Schizophrenia, bipolar disorder, major depressive disorder)
10. Has the participant been diagnosed with dementia (of any type)?
This includes diagnoses such as Alzheimer's disease, Vascular Dementia, Parkinson's disease dementia, Dementia with Lewy bodies, or other forms of dementia.
13. Is the participant currently being treated with a monoclonal antibody therapy for mild cognitive impairment or mild dementia related to Alzheimer’s disease?
18. Phone Number
19. Email Address
20. Is the participant aware of this referral?
21. Is the participant able to be contacted directly regarding this referral?
27. Is there any additional information that may be helpful for our team to know before we contact the participant? (optional)
28. Does the participant have a regular GP?
34. To your knowledge, is the participant being referred currently enrolled in another research study?
35. Name
36. Organisation
37. Phone Number
38. Email Address
39. Fax (if applicable)
40. Relationship to participant being referred
41. Reason for referral (please briefly describe)
42. How would you prefer to receive the Brain Health Report?