Self-referral form for TalkingZone

Page 1

1.1. Full Name Required

2.2. Preferred name Optional

3.3. Date of birth Required

(dd/mm/yyyy)

4.4. Phone number Optional

5.5. Email address Required

6.6. If your parents contact us or your school, can we inform them that you are receiving counselling? (we will only do this if necessary) Required

Yes

No

7.7. Are you happy for your Head of Year to know that you are receiving counselling? Required

Yes

No

8.8. What's been troubling you? Required

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

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

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

12.12. 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?

13.13. The following questions are about how you have been feeling OVER THE LAST WEEK. 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. Copyright CORE System Trust - Supported by www.coreims.co.uk Required

	Not at all	Only Occasionally	Sometimes	Often	Most or All of the Time
I've felt edgy or nervous
I haven’t felt like talking to anyone
I’ve felt able to cope when things go wrong
I’ve thought of hurting myself
There’s been someone I felt able to ask for help
My thoughts and feelings concern me
My problems have felt too much for me
It’s been hard to go to sleep or stay asleep
I’ve felt unhappy
I’ve done all the things I wanted to

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

Yes

No