Thank you for choosing to start your mental health recovery journey with us. Please be as honest as possible when answering the next few questions. 
Rest assured we will not share your results or responses with anyone other than you.
We look forward to helping you move forward.
Please note: filling in this preliminary screening does not mean you will be working with us. You will also need to have a 1-2-1 free consultation before you decide whether to take us on to help you.
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Your Full Name *

 
Your Age *

 
Your Gender *


 
I am the person who needs help: *

     
 
If you are answeing the questions on behalf of someone else please state how often you are with them on an average week:

 
For the next questions please indicate how often you have been bothered by each problem in the past two weeks using the following scale:

0 - Not at all
1 - less than 1-2 days
2 - several days
3 - more than half the days
4 - nearly every day
 
Little interest or pleasure in doing things? *

 
Feeling down, depressed or hopeless? *

 
Feeling more irritated, grouchy or angry than usual? *

 
Sleeping less than usual, but still have a lot of energy? *

 
Starting lots more projects than usual or doing more risky things than usual *

 
Feeling nervous, anxious, frightened, worried or on edge? *

 
Feeling panic or being frightened? *

 
Avoiding situations that make you anxious? *

 
Unexplained aches and pains (e.g., head, back, joints, abdomen, legs)? *

 
Feeling that you illnesses are not being taken seriously enough? *

 
Thoughts of actually hurting yourself? *

 
Hearing things that other people couldn't hear, such as voices even when no one was around? *

 
Feeling that someone could hear your thoughts, or that you could hear what another person was thinking? *

 
Problems with sleep that affected your sleep quality over all? *

 
Problems with memory (e.g., learning new information) or with location (e.g, finding your way home)? *

 
Unpleasant thoughts, urges, or images that repeatedly enter your mind? *

 
Feeling driven to perform certain behaviours or mental acts over and over again? *

 
Feeling detached or distant from yourself, your body, your physical surroundings or your memories? *

 
Not knowing who you really are or what you want out of life? *

 
Not feeling close to other people or enjoying your relationships with them? *

 
Drinking at least 4 drinks of any kind of alcohol in a single day? *

 
Smoking any cigarettes, a cigar, a pipe, using snuff or chewing tobacco? *

 
Using any of the following medicines ON YOUR OWN, that is, without a doctors prescription, in greater amounts or longer than prescribed: painkillers, stimulants, sedatives, or illegal drugs *

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