Sight Loss Self-Referral Sight Loss Referral General How did you find us? logo acf-forms activecampaign authorize aweber bootstrap campaignmonitor constant_contact getresponse googlesheets highrise hubspot mailchimp mailpoet paypal icon polylang salesforce salesforcealt stripe stripealt twilio woocommerce Zapier required delete move drag clear noclear duplicate copy clone tooltip tooltip_solid forbid checkmark image checkmark circle checkmark square check check1 plus plus1 plus2 plus3 plus4 minus minus1 minus2 minus3 minus4 cancel cancel1 close report_problem_solid report_problem arrowup arrowup1 arrowup2 arrowup3 arrowup4 arrowup5 arrowup5_solid arrowup7 arrowup6 arrowup8 arrowdown arrowdown1 arrowdown2 arrowdown3 arrowdown4 arrowdown5 arrowdown5_solid arrowdown7 arrowdown6 arrow_left arrow_right filter download upload2 download2 hard_drive pencil_solid pencil pencil-message signature register account_circle_solid account_circle address_card paragraph checkbox_unchecked checkbox checkbox_solid dropdown caret_square_down radio_unchecked scrubber location_solid location toggle_on toggle_off shield_check shield_check_solid clock clock_solid email_solid mail_bulk code tag tag_solid price_tags search sitemap file file_text_solid file_text option option_solid more_horiz more_vert more_horiz_solid more_vert_solid calculator key key Filled Key Icon keyboard eye eye_solid eye_slash_solid page_break view_day attach_file printer header h1 repeat repeater save sliders code_commit star star_full star_half star_feedback linear_scale pie_chart stats_bars sms feed align_right align_left button browser cloud_upload_solid shuffle swap pallet fingerprint ghost heart_solid heart history import export label_solid label lock_open lock alt_lock dollar_sign percent notification external_link pageview_solid pageview settings stamp support text white_label building icontact sendinblue sendy wordpress credit_card credit_card_alt cc_amex cc_discover cc_mastercard cc_visa cc_paypal icon cc_stripe price product total quantity directory Preview Internet Search Facebook Twitter Instagram Recommendation Other How would you like to be contacted? * Email Text Phone Other Sessions? What is the referral for? NHS Application Self-Pay NHS application + self-pay for quick start Other If self-pay, which plan? Not sure Introduction Session £50 Pay per session £70 Buy block of 3 sessions £180 (£60) Other Preference? (multi-select) Video Sessions Telephone Jointly Video & Phone Other 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 Other 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) Other Employment? Employed? Yes No Status Full-Time Part-Time Are You Medically or Physically Able to Work? Yes No Other 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 Other Medical Medication? (multi-select if needed) None Antidepressants Antipsychotics Anti-Anxiety Heart Medication Diabetes Medication Mood Stabilisers Stimulants Other 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 Other 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 Other 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 Other Approx When? This year Last year within last 5 years 6 years or more ago Aprox, Number of Sessions 1-5 6-10 10-15 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
