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General Questionnaire
Complex Care Counselling
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General Questionnaire
General Disabilities Questionnaire
Address & Contact
Your Name?
*
PostCode?
*
Date of Birth
*
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GP Details
Surgery Name
Postcode
Dr Name (if Known)
Email (if Known)
Phone (if Known)
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Home?
Relationship?
Single
Divorced
Live-In-Partner
Married
Children?
Yes
No
Under 18 & living at home
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Employment?
Employed?
Yes
No
Status
Full-Time
Part-Time
Are You Medically or Physically Able to Work?
Yes
No
Other
Other
Are You Retired?
Yes
No
Are you a student?
Yes
No
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Aspirations?
Multi-select
Facilitating behaviour change
Enhancing coping skills
facilitating your potential
Development of self-worth
Improving relationships
Reduce anger
Reduce negative feeling and thoughts
Explore broad set of issues
Reduce or remove addictions
Establish and maintain relationships
Remove or reduce negative cycles
Other
Other
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What Would You Like Help With?
Multi-Select Available
Addictions
Anger
Anxiety
Body Dysmorphia
Chronic Fatigue Syndrome
Chronic Pain
Depression
Dissociative Disorders
Health Anxiety
Fibromyalgia
OCD
Continued
Psychosis
Panic Disorder
Personality Disorder
Phobias
PTSD
Social Anxiety
Stress
Suicidal Thought
Self-Harm Thoughts
Other
Other
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Do you have any of the following?
Please Select? Multi-select available
No
Learning Difficulties (general)
Autism/Aspergers
Fragile x
Developmental Delay
Challenging Behaviours
Epilepsy
Other
Other
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Disability, Injury or Issue?
Do you have a disability?
No
Yes
Please write a brief outline of your disability
Do you have a medical problem?
No
Yes
What is your medical problem? (multi-select)
Alzheimers
Arthritis
Asthma
Blood Pressure
Cancer
Infectious Disease
Lung Conditions
Diabetes
Heart Issues
Stroke
Other
Other
Do you take Medication?
None
Antidepressants
Antipsychotics
Anti-Anxiety
Heart Medication
Diabetes Medication
Mood Stabilisers
Stimulants
Other
Other
Please write a brief outline of your medical problem
Is your problem related to food?
No
Yes
Please write a brief outline of your food problem
Is your problem related to addictions?
No
Yes
Please write a brief outline of your addictions problem
Is your problem related to phobias?
No
Yes
Please write a brief outline of your phobia problem
Is your problem related to a Injury?
No
Yes
Please write a brief outline of your injury problem
Is your problem related to a neurological issue?
No
Yes
Please write a brief outline of your neurological problem
Is your problem related to assault?
No
Yes
Please write in type of assault (not details of the assault)
Please insert type of assault
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Are you in dispute with any authorities or persons?
No
Person
NHS
Employer
Organisation
Other
Other
Legal
Is your dispute going to court or litigation?
No
Yes
Other
Other
Briefly explain the dispute.
Briefly explain at what stage you are at with the courts or litigation and any possible timelines.
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Assistive Devices
Mobility Device?
*
Not Needed
Crutches
Supporting frame
Tilt-in-space
Manuel wheelchair
Standing wheelchair
Motorised wheelchair
Standing frame
Other
Other
Assistive Technology?
*
Not Needed
Electronic communication board
Low-tech communication board
Speech-generating device
Eye-tracking device
Typing and writing devices
Hearing Aids
Cochlear Implant
Other
Other
Multi-select
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Do you have a carer?
No
Yes
Other
Other
Carer Questions?
Is you carer?
Parent
Partner
Social Services
Other
Other
Carer hours?
1-4 hours daily
5 – 8 hours daily
Live-in
Assisted living at home
Assisted living (social services)
Other
Other
Any carer problems?
No – excellent care
No – good care
General poor care
Multiple carers
Personality clash
Other
Other
Anything to add about carer?
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Do you have difficulty looking after your home, e.g., DIY, housework, cooking?
No
Yes
Cannot do
Daily Mobility Questions
Do you have difficulty carrying bags of shopping?
No
Yes
Cannot do
Do you have problems walking half a mile?
No
Yes
Carer Assistance
Do you have problems walking 100 yards?
No
Yes
Cannot do
Any problems with your speech?
No
Yes – poor accessibility
Yes – socially anxious
Do you have problems writing clearly?
No
Yes
Do you feel frightened or worried about falling over in public?
No
Yes
Sometimes
Do you have difficulty getting around in public?
No
Yes – poor accessibility
Yes – socially anxious
Needed someone else to accompany you when you went out?
No
Yes
Sometimes
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Pain & Social Anxieties
Do you have daily chronic pain?
No
Yes
Other
Other
Do you have muscle cramps & spasms?
No
Yes
Other
Other
Do you favour one side of your body?
No
Yes
Other
Other
Can you feel unpleasantly hot or cold?
No
Yes
Other
Other
Do you feel anxious in public?
No
Yes
Sometimes
Do you lack support in the ways you need from family or close friends
No
Yes
Sometimes
Do you feel ignored by people?
No
Yes
Sometimes
Do you feel confined to the house more than you would like?
No
Yes
Sometimes
Do you feel shamed in public?
No
Yes
Sometimes
Do you feel worried about people’s reactions to you?
No
Yes
Sometimes
Do you feel accessible services in public spaces hinder your ability to have a normal life?
No
Yes
Sometimes
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Mental Health Questions based on “you have or do you”?
Q1 – Little interest in doing things?
Never
Few Days
Most Days
Almost Every Day
Q2 – Feel down or depressed?
Never
Few Days
Most Days
Almost Every Day
Q3 -Have little sleep, or sleeping too much?
Never
Few Days
Most Days
Almost Every Day
Q4 -Feel tired or have little energy?
Never
Few Days
Most Days
Almost Every Day
Q5 – Poor appetite or overeating?
Never
Few Days
Most Days
Almost Every Day
Q6 -Feel bad about yourself or let family down?
Never
Few Days
Most Days
Almost Every Day
Q7 – Trouble concentrating on things?
Never
Few Days
Most Days
Almost Every Day
Q8 – Suicidal or self-harm thoughts?
Never
Few Days
Most Days
Almost Every Day
Q9 – Feel nervous, anxious or on edge?
Never
Few Days
Most Days
Almost Every Day
Q10 – Can you stop or control worrying?
Never
Few Days
Most Days
Almost Every Day
Q11 – Becoming easily annoyed or irritable?
Never
Few Days
Most Days
Almost Every Day
Q12 – Worry something awful might happen?
Never
Few Days
Most Days
Almost Every Day
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NHS Past Counselling?
Any, Past Counselling?
*
Yes
No
Approx, how many years ago?
Approx, how many sessions?
Any other NHS sessions ?
No
Yes
Approx, how many years ago?
Approx, how many sessions?
Any other NHS sessions??
No
Yes
Details on how many and year approx
Would you like to add anything about past experiences with NHS counselling?
Experience of NHS Counselling
Did not understand my life circumstances
Good
Poor
Other
Other
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What other counselling
No
Self-paid
Employer provided
School or university
Insurance
Profesional organisation
Other
Other
Any other counselling? (not NHS paid)
Could you add the approx year & how many sessions?
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Anything you would like to add?
Brief Summary
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Confirmation
Signature
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Submit