Assessment form

Please fill the following form to start

  1. Please outline the issue(s) for which you are seeking a consultation
  2. Have you tried anything else to improve matters?
  3. Have you suffered any loss, important change, or trauma?
  4. Are you currently, or have in the past, harmed yourself or someone else in some way?
  5. Do you have any current or previous physical health issues or any psychological diagnoses? Please give details including any regular medication/treatment.
  6. Please describe who lives with you at home and their relationship to you
  7. How happy are you with your home circumstances?
  8. How happy are you with where you live?
  9. Do you feel safe at home?

    What would you like help with?

    Patient Health Questionnaire (PHQ)

    Looking at the last two weeks of your life, how often have you been bothered by the following problems.

    Generalised Anxiety Disorder Assessment (GAD)

    Looking at the last two weeks of your life, how often have you been bothered by the following problems?

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