Your Details First Name * Middle Name Last Name * Date of Birth * Day12345678910111213141516171819202122232425262728293031 Day MonthJanFebMarAprMayJunJulAugSepOctNovDec Month Year19231924192519261927192819291930193119321933193419351936193719381939194019411942194319441945194619471948194919501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017201820192020202120222023 Year NHS Number Email * Street Address * Street Address Line 2 City Postcode * Phone Number * Alternative Phone Number Preferred Communication Method(s) Phone Email Postal Mail SMS Privacy Preferences Are there any communication methods that you would prefer us NOT to use: Do not email Do not phone Do not mail Do not sms Medical Details GP Practice / Medical Centre * Please provide a brief description of your problem, including details of any previous or current mental health problems * Diagnosis * Agoraphobia Anxiety Asthma Bipolar Blood pressure Cholesterol Depression Diabetes Eating disorder Hearing voices Isolated Loneliness Long term health condition Low mood Obsessive Compulsive Disorder Panic attacks Psychosis Schizophrenia Self harm Stress Do you have any Long Term Physical Health Condition? Asthma Cancer Chronic Kidney Disease Chronic Obstructive Pulmonary Disease Coronary Heart Disease Dementia Non Insulin Dependent Diabetes Mellitus Insulin Dependent Diabetes Mellitus Epilepsy Heart Failure Hypertension Multiple Sclerosis Parkinson's Disease Severe Mental Health Problems Stroke and Transient Ischaemic Attack Musculoskeletal Disorder Other Prefer not to say Do you have any additional needs? Require help from a support worker Wheelchair user BSL / Hearing Sight Are you currently pregnant? Yes No Have you been prescribed any medication for the condition you are seeking support for? Yes No Have you accessed any counselling before? * Yes No If so, when and where? * Have you or a family member been a victim of crime? Yes No If so, please give more details Do you have any money worries? Yes No If so, please give details Demographic Information Employment Status - Select -EmployedSelf EmployedNot WorkingRetiredStudentCarer Do you require an interpreter or help with Communication? * Yes No What is your first language? * Ethnicity - Select -PakistaniBangladeshiArabIndianWhite/BritishAfro/CaribbeanOther Do you follow a Religion? - Select -MuslimChristianJewishBuddhistSikhAtheistHumanistJainOther Gender - Select -FemaleMaleTransgenderOther Sexuality - Select -GayLesbianBisexualHeterosexualOtherNot disclosedNot asked Dependants / Carers Are you a carer? * Yes No Do you have a carer? * Yes No Carer's Name and Contact Details * What are your living arrangements? - Select -Living with parents/extended familyLiving with immediate family only (e.g. spouse and children)Living alone How did you hear about us? We are open Monday to Friday, 9:15am to 4:30pm - what times are you generally available during the week? Consent * Children and young people aged 16 years and under will require consent from their parent, or someone with parental responsibility for them. I am aged 16 or under I am over 16 Contact Details for Parent/Guardian * CAPTCHA This question is for testing whether or not you are a human visitor and to prevent automated spam submissions. Submit
