Intake Form

Intake Form

Your Details

Your Next of Kin

Your GP

Please answer the following questions as best you can

GENERAL HEALTH AND MENTAL HEALTH INFORMATION

ANXIETY

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
If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?

DEPRESSION

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
6. Feeling bad about yourself — or that you are a failure or have let yourself or your family down
7. Trouble concentrating on things, such as reading the newspaper or watching television
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
9. Thoughts that you would be better off dead or of hurting yourself in some way

WORK AND SOCIAL ADJUSTMENT SCALE

Mental health can affect one's ability to do certain day-to-day tasks in their lives. Please read each item below and respond based on how much your mental health impairs your ability to carry out the activity.
1. Because of my mental health my ability to work is impaired. ‘0’ means ‘not at all impaired’ and ‘8’ means very severely impaired to the point I can't work.
2. Because of my mental health my home management (cleaning, tidying, shopping, cooking, looking after home or children, paying bills) is impaired
3. Because of my mental health my social leisure activities (with other people e.g. parties, bars, clubs, outings, visits, dating, home entertaining) are impaired
4. Because of my mental health, my private leisure activities (done alone, such as reading, gardening, collecting, sewing, walking alone) are impaired.
5. Because of my mental health, my ability to form and maintain close relationships with others, including those I live with, is impaired.

ADDITIONAL INFORMATION