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Barnet 17-25 Mental Health Support Services
Submitted by
sarah@gmcvodata...
on Thu, 11/02/2021 - 13:44
Are you a professional or parent/carer?
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Yes
No
Professional or parent/carer details
First Name
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Last Name
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Organisation
Phone Number
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Email
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Reason for referral? Please Note: this is a short term therapy service. Therefore we do not see clients with severe and enduring mental health difficulties such complex trauma)
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Young Person's Details
First Name
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Last Name
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Birth Date
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Day
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Street Address
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Street Address Line 2
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Street Address Line 3
City
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Postal Code (Home)
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Postcode of place of study or work (Data purposes only)
Mobile Phone Number (so we can send you a SMS reminder)
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Email
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NHS number (Data purposes only for local need)
GP name and address (Data purposes only)
Ethnicity
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White-British
White-Irish
Any other White background
Black/Black British-Caribbean
Black/Black British-African
Any other Black background
Black Caribbean and White
Black African and White
Asian and White
Any other mixed background
Chinese
Bangladeshi
Indian
Pakistani
Any other Asian background
Any other ethnic group
Prefer not to say
Not known
Have you attempted suicide in the past? It’s very common for people to have thoughts about being better off dead or hurting themselves in some way, but often it’s because they want their distress to end, rather than wanting to end their own life)
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Yes
No
If yes, please state when
What areas would you like to focus on?
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Building self esteem
Confronting anxiety provoking situations
Managing difficult emotions
Other
If other, please tell us what.
Below are the conditions we work with, please select the appropriate condition
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Anxiety
Emotional Dysregulation
Exam Stress
Low Mood
Phobias
Panic Attacks
Sleep Difficulties
Stress
Unhealthy Habits
Worry
Please tell us more if you can?
Onset: When did this mental/emotional health problem start?
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What would you like to change in your life with therapy?
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Are you living with any long-term health conditions?
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Yes
No
Are you taking any psychiatric medication?
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Yes
No
If yes, please state what
Have you ever experienced trauma? (For example: experiencing recurring nightmares; unwanted thoughts about an event; reexperiencing emotions associated with the traumatic event; flashbacks; feeling like the trauma is happening).
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Yes
No
Prefer not to say
Do you have any additional educational needs, i.e. Dyslexia?
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Yes
No
If yes, please state what
Are you registered disabled?
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Yes
No
Do you identify as the gender which you were given at birth?
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Yes
No
Are you a carer?
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Yes
No
