Sight Loss Self-Referral Sight Loss Referral General How did you find us? Internet Search Facebook Twitter Instagram Recommendation OtherOther How would you like to be contacted? * Email Text Phone OtherOther Sessions? What is the referral for? NHS Application Self-Pay NHS application + self-pay for quick start OtherOther If self-pay, which plan? Not sure Introduction Session £50 Pay per session £70 Buy block of 3 sessions £180 (£60) OtherOther Preference? (multi-select) Video Sessions Telephone Jointly Video & Phone OtherOther Aspirations from counselling? Facilitating behaviour change Enhancing coping skills Facilitating your potential Development of self-worth Improving relationships Reduce anger Reduce negative feeling and thoughts Explore broad set of issues Reduce or remove addictions Establish and maintain relationships Remove or reduce negative cycles OtherOther Address & Contact Your Name? PostCode? Date of Birth? Phone Number Email Gender? GP Details Surgery Name Postcode Dr Name (if Known) Home? Relationship? Single Divorced Live-In-Partner Married Other Have you got a carer? Not needed Yes – Part-Time Yes – Full-Time No – but need one Do you have children? Yes No How many? 1 2 3 4 5 5+ Other Do they live with you? Live-at-Home Adult (my full-time carer) Now Adults (left home) OtherOther Employment? Employed? Yes No Status Full-Time Part-Time Are You Medically or Physically Able to Work? Yes No OtherOther Are You Retired? Yes No Are You A Carer? Yes No Are you a student? Yes No Your Vision? Vision Scale Blind (100%) Blind (80% & Over) Sight Loss (50% & Over) Vision Impaired (30% & Over) Poor Vision (up to 30%) Vision? One eye Both eyes Reasoning? Unexplained (Sudden Acquired) Trauma (Sudden Acquired) Gradual Reducing Medical Do you feel your vision loss is the basis of your mental health issues? No Yes Partly Mobility Mobility Device? Not needed Walking stick Guide dog Both walking stick & guide dog Wheelchair user Motorised wheelchair Supporting frame OtherOther Medical Medication? (multi-select if needed) None Antidepressants Antipsychotics Anti-Anxiety Heart Medication Diabetes Medication Mood Stabilisers Stimulants OtherOther Any Medical Issues? Yes No What? (multi-select) Alzheimers Arthritis Asthma Blood Pressure Cancer Infectious Disease Lung Conditions Diabetes Neurological Issues Eyesight Problems Hearing/Ear Heart Issues Stroke OtherOther Anything to add Medically? What Would You Like Help With? Multi-Select Available Addictions Anger Anxiety Body Dysmorphia Chronic Fatigue Syndrome Chronic Pain Depression Dissociative Disorders Health Anxiety Fibromyalgia OCD Continued Psychosis Panic Disorder Personality Disorder Phobias PTSD Social Anxiety Stress Suicidal Thought Self-Harm Thoughts OtherOther Mental Health Questions based on “you have or do you”? Q1 – Little interest in doing things? Never Few Days Most Days Almost Every Day Q2 – Feel down or depressed? Never Few Days Most Days Almost Every Day Q3 -Have little sleep, or sleeping too much? Never Few Days Most Days Almost Every Day Q4 -Feel tired or have little energy? Never Few Days Most Days Almost Every Day Q5 – Poor appetite or overeating? Never Few Days Most Days Almost Every Day Q6 -Feel bad about yourself or let family down? Never Few Days Most Days Almost Every Day Q7 – Trouble concentrating on things? Never Few Days Most Days Almost Every Day Q8 – Suicidal or self-harm thoughts? Never Few Days Most Days Almost Every Day Q9 – Feel nervous, anxious or on edge? Never Few Days Most Days Almost Every Day Q10 – Can you stop or control worrying? Never Few Days Most Days Almost Every Day Q11 – Becoming easily annoyed or irritable? Never Few Days Most Days Almost Every Day Q12 – Worry something awful might happen? Never Few Days Most Days Almost Every Day Past Counselling? Any, Past Counselling? Yes No How Were They Funded? NHS RNIB Employment Support Self-Paid OtherOther Approx When? This year Last year within last 5 years 6 years or more ago Aprox, Number of Sessions 1-5 6-10 10-1510-15 16 -20 20+ Brief Summary Please explain as briefly as possible what your current issues are? If you are human, leave this field blank. Submit
