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Self-Referral

Information provided on this form may be visible to Wix. Once received, I am required to store a copy for seven years to comply with my public liability insurance requirements. If you prefer, please feel free to print this page and bring your responses to our first session on paper.

Main difficulties

Select all issues which apply:

Symptoms of low mood

Over the last two weeks, have any of the following been a problem:

1. Little interest or pleasure in doing things?
Not at all
Several days
More than half the days
Nearly every day
2. Feeling down, depressed, or hopeless?
Not at all
Several days
More than half the days
Nearly every day
3. Trouble falling or staying asleep, or sleeping too much?
Not at all
Several days
More than half the days
Nearly every day
4. Feeling tired or having little energy?
Not at all
Several days
More than half the days
Nearly every day
5. Poor appetite or overeating?
Not at all
Several days
More than half the days
Nearly every day
6. Feeling bad about yourself, that you are a failure or have let yourself down?
Not at all
Several days
More than half the days
Nearly every day
7. Trouble concentrating on things, such as reading the newspaper or watching television?
Not at all
Several days
More than half the days
Nearly every day
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?
Not at all
Several days
More than half the days
Nearly every day
9. Thoughts that you would be better off dead or of hurting yourself in some way?
Not at all
Several days
More than half the days
Nearly every day

Symptoms of anxiety

Over the last two weeks, have any of the following been a problem:

1. Feeling nervous, anxious, or on edge?
Not at all
Several days
More than half the days
Nearly every day
2. Not being able to stop or control worrying?
Not at all
Several days
More than half the days
Nearly every day
3. Worrying too much about different things?
Not at all
Several days
More than half the days
Nearly every day
4. Trouble relaxing?
Not at all
Several days
More than half the days
Nearly every day
5. Being so restless that it's hard to sit still?
Not at all
Several days
More than half the days
Nearly every day
6. Becoming easily annoyed or irritable?
Not at all
Several days
More than half the days
Nearly every day
7. Feeling afraid as if something awful might happen?
Not at all
Several days
More than half the days
Nearly every day

Additional details

The data you provide on this form is processed in line with our privacy policy.

Please use the above form to provide the requested information. Alternatively, feel free to book your initial consultation first using the appropriate button below and then decide after this initial chat whether you would like to return to this page and provide the above self-referral information. 

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