If you have any difficulties in filling out the forms, please contact our team administrator on

Transcription

1 Westminster IAPT Primary Care Psychology Service Lisson Grove Health Centre Gateforth Street London NW8 8EG Team Administrator Tel: Dear Sir/Madam Thank you for requesting this opt-in pack from your surgery. This means that you have expressed an interest in receiving treatment from the Westminster Improving Access to Psychological Therapies Service. In order to get a better idea of your difficulties, we would be grateful if you could complete the enclosed registration form and questionnaire. Once completed, please leave them at the reception in the surgery. If there is information you would prefer not to disclose on the form, you may discuss this in person when you meet with your practitioner at assessment. If you have any difficulties in filling out the forms, please contact our team administrator on Once we have received the completed forms, we will then contact you by phone to either invite you to an information session, arrange an assessment appointment or discuss alternative options. Please tell us when the best time to call you is between 9am - 5pm, Monday Friday and we will try to contact you then. Please tick availability: Monday Tuesday Wednesday Thursday Friday am pm Kind regards, Maren Heldberg Psychological Wellbeing Practitioner Dr. Louise Oliver Clinical Psychologist Westminster IAPT Primary Care Psychology Service

2 REGISTRATION FORM FOR WESTMINSTER IAPT PRIMARY CARE PSYCHOLOGY SERVICE Please can you complete as much of the following as possible. This will allow us to make sure that we have correct information on your records. If you don t know the answer please leave the section blank. Use a to indicate your answer in the. IT IS VERY IMPORTANT THAT YOU TELL US IF YOU CHANGE ADDRESS OR TELEPHONE NUMBER AS WE WILL CONTINUE TO SEND INFORMATION AND LEAVE MESSAGES THERE UNTIL YOU TELL US OTHERWISE. DATE COMPLETED: PERSONAL DETAILS Gender: Male Female Surname: Forename(s): Date of Birth: NHS No (if known): Address: Postcode: Mobile No: Can we leave messages? Yes No Telephone No: Can we leave messages? Yes No Address: Marital Status: Occupation: ETHNICITY, NATIONALITY AND CULTURAL DETAILS: White (tick one box only) British (A) Irish (B) Other (C) Mixed White & Black Caribbean (D) White & Black African (E) White & Asian (F) Other (G) Please Specify Exact Ethnic Group: Nationality: Asian or Asian British Indian (H) Pakistani (J) Bangladeshi (K) Other (L) Black or Black British Caribbean (M) African (N) Arab (P) Other (P) Other Ethnic Group Chinese (R) Arab (S) Other (S) I do not wish to state (ZR) Are you able to read and write in English: Yes No What is your first language (if not English) Ability to read and write in First Language: Yes No General Practitioner (GP) Name:

3 DESCRIPTION OF THE DIFFICULTIES Clinical Problems: 1) Please describe the nature of your difficulties in your own words, mentioning the main problems, how they have developed, and your present condition: 2) In what ways do your difficulties affect your life at the present time? 3) Describe anything that makes it better or easier to deal with your difficulties? 4) Have you ever had treatment for these difficulties before? If yes, please describe what. 5) Do you drink/take alcohol and/or any recreational drugs? If so, please give details. 6) Please describe what your expectations are and what benefits you are hoping to get from psychological treatment?

4 Patient Code: Date: IAPT Employment Status Questions A14 - Please indicate which of the following options best describes your current status: Employed full-time (30 hours or more per week) Employed part-time Unemployed Full-time student Retired Full-time homemaker or carer A15 - Are you currently receiving Statutory Sick Pay? Yes No A16 - Are you currently receiving Job Seekers Allowance, Income support or Incapacity benefit? Yes No Work and Social Adjustment People's problems sometimes affect their ability to do certain day-to-day tasks in their lives. To rate your problems look at each section and determine on the scale provided how much your problem impairs your ability to carry out the activity. WORK - if you are retired or choose not to have a job for reasons unrelated to your problem, please tick N/A (not applicable) N/A, I cannot work HOME MANAGEMENT Cleaning, tidying, shopping, cooking, looking after home/children, paying bills etc SOCIAL LEISURE ACTIVITIES - With other people, e.g. parties, pubs, outings, entertaining etc. PRIVATE LEISURE ACTIVITIES Done alone, e.g. reading, gardening, sewing, hobbies, walking etc. FAMILY AND RELATIONSHIPS Form and maintain close relationships with others including the people that I live with A13 W&SAS total score

5 PHQ- 9 Over the last 2 weeks, how often have you been bothered by any of the following problems? Not at all Several More than half the Nearly every day 1 Little interest or pleasure in doing things 2 Feeling down, depressed, or hopeless 3 Trouble falling or staying asleep, or sleeping too much 4 Feeling tired or having little energy 5 Poor appetite or overeating Feeling bad about yourself or that you are a failure or have let yourself or your family down Trouble concentrating on things, such as reading the newspaper or watching television 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 Thoughts that you would be better off dead or of hurting yourself in some way GAD-7 Over the last 2 weeks, how often have you been bothered by any of the following problems? Not at all Several More than half the Nearly every day 1 Feeling nervous, anxious or on edge 2 Not being able to stop or control worrying 3 Worrying too much about different things 4 Trouble relaxing 5 Being so restless that it is hard to sit still 6 Becoming easily annoyed or irritable 7 Feeling afraid as if something awful might happen IAPT Phobia Scales Choose a number from the scale below to show how much you would avoid each of the situations or objects listed below. Then write the number in the box opposite the situation. Would not Slightly Definitely Markedly Always avoid it A17 A18 A19 Social situations due to a fear of being embarrassed or making a fool of myself Certain situations because of a fear of having a panic attack or other distressing symptoms (such as loss of bladder control, vomiting or dizziness) Certain situations because of a fear of particular objects or activities (such as animals, heights, seeing blood, being in confined spaces, driving or flying).

6 Don t forget info leaflet!!!!!!!!!!!!!!!!!