General Information
Q: Are you experiencing any of the following mental health issues?
A: Anxiety, Depression, Low Mood, Social Isolation, Loss/bereavement, Anger Management etc.
Q:On a scale of 1-10 (with 1 being ‘not at all’ and 10 being ‘very much’) please indicate how much these problems impact on your ability to go about your daily day-to-day life.
Q: Are you experiencing problems/issues with any of the following?
A: Money, Housing, Work, Relationship, Long term health condition etc.
Q: Do you consider yourself to have a disability, neurodiversity or long term health condition?
A: Yes/No
Q: Do you have any alcohol or drug related problems (please specify)
A: Yes/No
Q: Do you take non-prescription drugs?
A: Yes/No
Q: Do you take prescription drugs?
A: Yes/No
Q: Do you have a condition which may affect your memory, ability to learn/process and/or understand information
A: Yes/No
Q:Thinking about your financial situation, which of the below statements best describes your situation?
Q: Are you an unpaid carer (ie, you are not employed as a professional carer)
A: Yes/No/Maybe
Q: Are you a veteran
A: Yes/No
Q: Do you feel isolated or lonely
A: Yes/No
Q:Would benefit from a regular volunteer support call
A: Yes/No
Q: Are you accessing any other mental health services?
A: Community Counselling, Next Steps, Horizons
Q: As an equal opportunities organisation, we would like to ensure we meet your needs; do you have any specific requirements which would assist us to do this?
Q:Do you consider yourself to be a risk to yourself or others?
Q:Do you have anything else you would like us to know?
Q:GP Name and Surgery Name
Q: Where did you hear about the service?
Q: Details of Referral