Please remember to click the submit button once you complete this form in order to send it through to the service.
If you selected 'Other' for the workshop, please specify:
What is your surname?
Required
What are your forenames?
Required
What is your full address, including postcode?
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What is your gender?
Required
I prefer not to say Male Female Transgender Gender non binary Gender Fluid / Gender Queer
What is your ethnicity?
Required
Not Stated 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 Known
Please provide us with a contact number for you
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Please provide us with an email address for you
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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
Required
Not at all (0) Several days (1) More than half the days (2) Nearly every day (3)
2. Feeling down, depressed, or hopeless
Required
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
Required
Not at all (0) Several days (1) More than half the days (2) Nearly every day (3)
4. Feeling tired or having little energy
Required
Not at all (0) Several days (1) More than half the days (2) Nearly every day (3)
5. Poor appetite or overeating
Required
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
Required
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
Required
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
Required
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
Required
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
Required
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
Required
Not at all (0) Several days (1) More than half the days (2) Nearly every day (3)
3.Worrying too much about different things
Required
Not at all (0) Several days (1) More than half the days (2) Nearly every day (3)
4.Trouble relaxing
Required
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
Required
Not at all (0) Several days (1) More than half the days (2) Nearly every day (3)
6.Becoming easily annoyed or irritable
Required
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
Required
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
Required
0 1 2 3 4 5 6 7 8
Certain situations because of a fear of having a panic attack or other distressing symptoms (such as loss of bladder control, vomiting or dizziness)
Required
0 1 2 3 4 5 6 7 8
Certain situations because of a fear of particular objects or activities (such as animals, heights, seeing blood, being in confined spaces, driving or flying)
Required
0 1 2 3 4 5 6 7 8
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
Required
0 1 2 3 4 5 6 7 8
Home management – Cleaning, tidying, shopping, cooking, looking after home/children, paying bills etc
Required
0 1 2 3 4 5 6 7 8
Social leisure activities - With other people, e.g. parties, pubs, outings, entertaining etc.
Required
0 1 2 3 4 5 6 7 8
Private leisure activities – Done alone, e.g. reading, gardening, sewing, hobbies, walking etc.
Required
0 1 2 3 4 5 6 7 8
Family and relationships– Form and maintain close relationships with others including the people that I live with
Required
0 1 2 3 4 5 6 7 8
Additional note about GP contact: Through completing this form you are consenting to have this information stored confidentially on a secure electronic system separate from your GP’s system. If we are concerned about your safety, we may contact you or your GP regarding this.
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.
