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Sight Loss Questionnaire
Complex Care Counselling
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Sight Loss Questionnaire
Sight Loss Questionnaire
Questionnaire
Why?
Sight Loss is a complex condition, it has many variations, and you could have additional sensory or physical symptoms. This Questionnaire asks about your Sight Loss and any coexisting problems, the aim is to give your counsellor a full understanding before you start your first session.
Confidential
All information you enter into this online form is fully confidential. The information will be shared only with your specialist counsellor.
Self Paid Counselling
If you are not asking for a NHS application for free funding, you do not need to complete this questionnaire, its your choice. If this is the case just close this webpage.
For NHS Funded Counselling
If you would like DisabilityPlus to make a free funding application, we have to prove why you are best suited to a counsellor who has sight loss. As a disabilities company we know its just another hoop we have to jump through just like you do every day.
NHS Application
If DisabilityPlus are going to make an NHS application for the purpose of free funding. The information you insert will be used to make a free funding application for you.
Complexity
The form should not take more than 5 minutes to complete. We have made it as user-friendly as possible; however, if you feel you cannot complete it or would prefer a telephone call, select from the buttons after your contact details ” No, I would like a telephone call for help to complete it”.
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Your Contact Details (person who wants counselling)
Your Name?
*
PostCode?
*
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Funding
Type
Self-paid (immediate start)
Self-paid to start and a NHS application
NHS application only
Other
Other
Self-paying
On completion of this form you will start your sessions within two weeks. The pricing is: £50 introduction Session £180 for 3 sessions or £70 pay-as-you-go. Please talk to us if you are in financial difficulties.
NHS Funding
NHS Funding cannot be guaranteed, each NHS region has different rules. On selecting NHS application and completing this form you will receive a assessment session by our blind counsellor. We then send a application to your GP based on your unique circumstances, there is then generally a twelve week wait for a decision by the NHS to approve your funding or decline funding. You can self-pay to start counselling immediately and in the background we can make the application for you.
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Continue?
Continue to the form?
No, I would like a telephone call for help to complete it.
I want to continue to the form
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Who is completing this form?
Please tell us who is completing the form?
Myself
Partner
Carer
Mother/Father
Family memeber
Social services
Other
Other
If one or more people are completing this form multi-select from the answers above.
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Next
GP Details
Surgery Name
Postcode
Dr Name (if Known)
GP Email (if known)
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Home?
Relationship status?
Single
Divorced
Live-In-Partner
Married
Children living at home?
Yes
No
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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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Next
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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Sight Loss Type?
Registered?
Vision Loss 25%
Vision Loss 50%
Vision Loss 75%
Registered Blind
Other
Other
Your Sight Loss?
Blurred vision (refractive errors)
Age-related macular degeneration
Glaucoma
Cataract
Diabetic retinopathy
Other
Other
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Carer Questions?
Do you have a carer?
No
Yes
Other
Other
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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Any, Additional Disabilities
Do you have any additional disabilities?
No
Autism
Epilepsy
Hearing Loss
Medical Illness
Other
Other
Hearing Loss
Mild
Moderate
Severe
Deaf/BSL User
Other
Other
Sight Loss
Mild
Moderate
Severe
Blind
Other
Other
Epilepsy Type?
Absence
Clonic
Focal
Generalised
Tonic-Clonic
Other
Other
Absence
Absence seizures are more common in children than adults and can happen very frequently. During an absence a person becomes unconscious for a short time. They may look blank and stare, or their eyelids might flutter. They will not respond to what is happening around them. If they are walking they may carry on walking but will not be aware of what they are doing.
Clonic
Clonic seizures involve repeated rhythmical jerking movements of one side or part of the body or both sides (the whole body) depending on where the seizure starts. Seizures can start in one part of the brain (called focal motor) or affect both sides of the brain (called generalised clonic).
Focal
As the seizure progresses, a person can experience motor and non-motor symptoms. Some motor symptoms of focal seizures include: muscle twitching jerking spasms repeated movements, like clapping or chewing Non-motor symptoms do not affect how someone moves. However, they may cause confusion or changes in emotions. Some non-motor symptoms of focal seizures include: waves of hot or cold goosebumps lack of movement changes in emotions or thoughts
Generalised
Generalised onset seizures affect both sides of the brain at once and happen without warning. The person will be unconscious (except in myoclonic seizures), even if just for a few seconds and afterwards will not remember what happened during the seizure. Unknown onset seizures are sometimes used to describe a seizure if doctors are not sure where in the brain the seizure starts. This may happen if the person was asleep, alone or the seizure was not witnessed. If there is not enough information about a person’s seizure, or if it is unusual, doctors may call it an unclassified seizure.
Tonic Clonic
These are the seizures that most people think of as epilepsy. The person becomes unconscious their body goes stiff and if they are standing up they usually fall backwards. They jerk and shake as their muscles relax and tighten rhythmically.
Other Epilepsy
Best describe what other Epilepsy is
What medical illness?
What is the other?
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Health
Do you take medication?
None
Antidepressants
Antipsychotics
Anti-Anxiety
Heart Medication
Diabetes Medication
Mood Stabilisers
Stimulants
Other
Other
Any Medical Issues? (excluding sight loss)
Yes
No
What? (multi-select)
Alzheimers
Arthritis
Asthma
Blood Pressure
Cancer
Infectious Disease
Lung Conditions
Diabetes
Heart Issues
Stroke
Other
Other
Anything to add Medically?
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Anxieties
Do you feel ignored by people?
No
Yes
Sometimes
Do you lack support in the ways you need from your partner or spouse?
No
Yes
Sometimes
Do you feel worried about people’s reactions to you?
No
Yes
Sometimes
Do you feel shamed in public?
No
Yes
Sometimes
Do you feel confined to the house more than you would like?
No
Yes
Sometimes
Do you feel accessible services in public spaces hinder your ability to have a normal life?
No
Yes
Sometimes
Does sight loss affect your close personal relationships?
No
Yes
Sometimes
Do you feel frightened or worried about falling over in public?
No
Yes
Do you feel people try and take away your independence by over sympathising
No
Yes
Sometimes
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
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NHS Past Counselling?
Any, Past NHS Counselling?
*
Yes
No
How many and year approx
Any other NHS sessions?
No
Yes
How many and year approx
Any other NHS sessions ?
No
Yes
How many and year approx
Experience of NHS Counselling
Did not understand sight loss
Poor
Good
Other
Other
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Any other counselling? (not NHS)
Have you received counselling that was not NHS paid?
No
Yes
What other counselling
Self-paid
Employer provided
School or university
Insurance
Profesional organisation
Other
Other
Could you add the approx year & how many sessions?
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Assessment
Do you ever feel like life is not worth living?
No
Few Days
Most Days
Almost Every Days
Have you ever tried to commit suicide?
No
Yes
Other
Other
How often do you have suicidal thoughts?
Few Days
Most Days
Almost Every Days
Do you know how to end your life?
No
Yes
Other
Other
Have you made plans to end your life?
No
Yes
Other
Other
Do you ever feel like self harming?
No
Yes
Other
Other
Have you self harmed in the past?
No
Yes
Other
Other
Other, do you ever feel like self-harming?
Best describe your thoughts
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Brief Summary
Would you like to add anything?
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If you are human, leave this field blank.
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