Counselling for Young People Self-referral form

Page 1

1.1. First Name Required

2.2. Surname Required

3.3. Date of birth Required

(dd/mm/yyyy)

4.4. Phone number Required

5.5. Email address Required

6.6. What's been troubling you? Required

7.7. Is there anything you have done so far that may have helped? Required

8.8. What do you feel like doing when your troubles seem at their worst? Required

9.9. What would you be doing differently if things were getting better? Required

10.10. Are there any people helping you with your troubles and who have you asked for help in the past? Required

This part of the survey uses a table of questions, view as separate questions instead?

11.11. The following questions are about how you have been feeling OVER THE LAST TWO WEEKS. Please read each question carefully. Think how often you have felt like that in the last week and then tick the box you think fits best. Required

	Strongly Agree (3)	Mostly Agree (2)	Mostly Disagree (1)	Strongly Disagree (0)	Don't Know (0)
I feel unhappy or cry a lot
I feel less like talking to anyone
I feel angry or lash out at people
I feel nervous or panicky
I feel tired or struggle to sleep
I feel the way I behave will get me into serious trouble
It’s hard to stay friends or make new friends
I don't always like myself
My troubles make school life tough
My troubles make my home life tough

12.12. I have read and agree to the privacy notice Required

Yes

No