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Registration form for CNWL Talking Therapies Service Brent

Welcome to Brent Talking Therapies and thank you for your interest in attending one of our workshops. We offer workshops to help people manage a number of problems such as worry, low mood, stress and more. Our workshops are delivered by trained Psychological Wellbeing Practitioners and Psychological Therapists.

As an NHS service, we are obliged to take the following information to ensure our support is reaching everyone in the borough of Brent.

The questionnaires below can give you and us an indication of your current mental wellbeing and help us to ensure the workshop will be supportive to your needs.

All the information you provide is kept confidential and will not be shared with any other organisation. If you have any further questions about this, please do not hesitate to contact us on 020 8206 3940 or by email at cnw-tr.brent.iapt@nhs.net.

We look forward to speaking to you soon.

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Brent
Registration form for CNWL Talking Therapies Service Brent

Date completed Required

We deliver workshops to community organisations, which are listed below. Webinars that are open to the general public will be listed as 'Brent Talking Therapies'.

What is your surname? Required

What are your forenames? Required

What is your date of birth? Required

What is your postcode? Required

What is your gender? Required

Male

Female

Transgender

Gender non binary

Gender Fluid/ Gender Queer

I prefer not to say

What is your ethnicity? Required

White - British

White - Irish

White - Any Other White Background

Black or Black British - African

Black or Black British - Caribbean

Black or Black British - Any Other Black Background

Asian or Asian British - Bangladeshi

Asian or Asian British - Pakistani

Asian or Asian British - Indian

Asian or Asian British - Any Other Asian Background

Mixed - White and Black African

Mixed - White and Black Caribbean

Mixed - White and Asian

Mixed - Any Other Mixed Background

Other Ethnic Groups - Chinese

Other Ethnic Groups - Any Other Ethnic Group

Not Stated

Not Known

Please provide us with a contact number for you Required

Please provide us with an email address for you Required

How did you hear about the workshop/webinar? (e.g. Facebook, flyer, etc) Required

PHQ-9

Over the last two weeks, how often have you been bothered by any of the following problems?

1. Little interest or pleasure in doing things

Not at all (0)

Several days (1)

More than half the days (2)

Nearly every day (3)

Feeling down, depressed, or hopeless

Not at all (0)

Several days (1)

More than half the days (2)

Nearly every day (3)

3. Trouble falling or staying asleep, or sleeping too much

Not at all (0)

Several days (1)

More than half the days (2)

Nearly every day (3)

4. Feeling tired or having little energy

Not at all (0)

Several days (1)

More than half the days (2)

Nearly every day (3)

5. Poor appetite or overeating

Not at all (0)

Several days (1)

More than half the days (2)

Nearly every day (3)

6. Feeling bad about yourself — or that you are a failure or have let yourself or your family down

Not at all (0)

Several days (1)

More than half the days (2)

Nearly every day (3)

7. Trouble concentrating on things, such as reading the newspaper or watching television

Not at all (0)

Several days (1)

More than half the days (2)

Nearly every day (3)

8. Moving or speaking so slowly that other people could have noticed? Or the opposite — being so fidgety or restless that you have been moving around a lot more than usual

Not at all (0)

Several days (1)

More than half the days (2)

Nearly every day (3)

9. Thoughts that you would be better off dead or of hurting yourself in some way

Not at all (0)

Several days (1)

More than half the days (2)

Nearly every day (3)

GAD-7

Over the last two weeks, how often have you been bothered by any of the following problems?

1.Feeling nervous, anxious or on edge

Not at all (0)

Several days (1)

More than half the days (2)

Nearly every day (3)

2.Not being able to stop or control worrying

Not at all (0)

Several days (1)

More than half the days (2)

Nearly every day (3)

3.Worrying too much about different things

Not at all (0)

Several days (1)

More than half the days (2)

4.Trouble relaxing

Not at all (0)

Several days (1)

More than half the days (2)

Nearly every day (3)

5.Being so restless that it is hard to sit still

Not at all (0)

Several days (1)

More than half the days (2)

Nearly every day (3)

6.Becoming easily annoyed or irritable

Not at all (0)

Several days (1)

More than half the days (2)

Nearly every day (3)

7.Feeling afraid as if something awful might happen

Not at all (0)

Several days (1)

More than half the days (2)

Nearly every day (3)

Phobia scales

Put a number next to the situations or objects below to show how much you would avoid it. 0 being you would never avoid it to 8 being you would always avoid it.

Social situations due to a fear of being embarrassed or making a fool of myself

Certain situations because of a fear of having a panic attack or other distressing symptoms (such as loss of bladder control, vomiting or dizziness)

Certain situations because of a fear of particular objects or activities (such as animals, heights, seeing blood, being in confined spaces, driving or flying)

Work and Social Adjustment

People's problems sometimes affect their ability to do certain day-to-day tasks in their lives. To rate your problems look at each section and determine on a scale how much your problem impairs your ability to carry out the activity. With 0 being "not at all" to 8 being "very severely."

Work

Home management – Cleaning, tidying, shopping, cooking, looking after home/children, paying bills etc

Social leisure activities - With other people, e.g. parties, pubs, outings, entertaining etc.

Private leisure activities – Done alone, e.g. reading, gardening, sewing, hobbies, walking etc.

Family and relationships– Form and maintain close relationships with others including the people that I live with

Our Talking Therapies Services are not able to provide immediate support in an emergency. If you require immediate help please contact your GP, or your local Accident & Emergency Department, or call the Urgent Advice Line on 0800 0234 650 open 24 hours

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Registration form for CNWL Talking Therapies Service Brent

PHQ-9

GAD-7

Phobia scales

Work and Social Adjustment

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