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Surname*
First Name*
Preferred Name
Pronouns
Address line 1
Address line 2
Address line 3
Town
Postcode
GP Surgery
Landline Telephone No.
Mobile Telephone No.
Primary Email Address
Contact Instructions
Consent to hold information on the database
Would you like to hear from us for updates on our services, events and Mental Health training opportunities?
Service Required
Preferred Appointment Time(s)/Day(s)
How would you prefer to meet?
Can we leave a voicemail?
How did you hear about us?
Preferred Method of Contact*
Gender
Sex
Date of Birth
Marital Status
Sexual Orientation
Ethnic Group
Religious Group
Do you consider yourself to have a physical disability or long term health condition?
If yes, please provide details of the physical disability or long term health condition
Main Language
Limited Availability
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
How are you currently feeling? (0: 0, 10: 10)
How are you currently coping? (0: 0, 10: 10)
1. How do you feel at this moment? What is the reason you wish to seek counselling?
2. Who is supportive in your life? E.G. Family, Friends, Colleagues etc.
3. Have you received counselling before?
4. What do you want to achieve from counselling? What are your goals?
5. Are you currently being supported by a mental health team or any other organisation?
6. Are you being prescribed any medication for your mental health?
7. Do you have a mental health diagnosis
8. Do you currently self-harm or have suicidal thoughts?
Self-Request for Support
Details of referring organisation (if applicable):
Have you been affected by the loss of someone to suicide?
If you are comfortable sharing, can you tell us who you have lost?
Please share what practical support you feel you need:
Are you experiencing any current difficulties with your mental health?
Is there any other information you feel would be useful for us to know:
Please fill out this information so we know the best way to help you.
Are you currently being supported by a mental health team or any other organisation?
If Yes please give details
Is there any other information we should know?
Epilepsy or seizures?
Severe motion sickness or vertigo?
Serious visual impairment affecting headset use?
Do you feel comfortable using VR technology?
What has led you to seek support at this time?
What would you hope to gain from taking part in this programme?
How would you describe your current mental wellbeing?
Stress or overwhelm
Anxiety
Low mood
Difficulty sleeping
Difficulty relaxing
Other
Other please describe
Are you currently receiving any mental health support?
Are you currently experiencing thoughts of harming yourself?
Do you feel safe at the moment?
If you would like to share anything further about this, please do so below:
Do you have any mental health conditions we should be aware of that may affect participation?
Are you currently taking any medication that may affect balance, concentration, or comfort using VR?
What helps you cope when things are difficult?
Is there anything that might make participating in this programme challenging for you?
Are you able to attend the full programme if offered a place?
Do you have any accessibility needs we should be aware of?