Intake Form

If you have not spoken to anyone at Icarus, please do so before completing the intake form, this enables us to keep track of new intakes and allocate you an apprpriate therapist. If this is the case, please call Icarus on 0333 987 5055. If you have already spoken with someone then please complete this form as fully as possible and be open and honest with your answers, this will enable your therapist to have a good understanding to begin treatment with you.

PERSONAL DETAILS

SERVICE DETAILS

  • Choose
  • Civillian
  • Military
  • Police
  • Fire Service
  • Prison Service
  • NHS
  • Choose
  • RN
  • RM
  • Army
  • RAF
  • Reserves
  • Choose
  • Serving
  • Retired
  • Veteran

NEXT OF KIN DETAILS

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  • Mother
  • Father
  • Wife
  • Husband
  • Partner
  • Other

GP DETAILS

GENERAL PHYSICAL & MENTAL HEALTH HISTORY

  • Choose
  • Poor
  • Unsatisfactory
  • Satisfactory
  • Good
  • Very good
  • Choose
  • Poor
  • Unsatisfactory
  • Satisfactory
  • Good
  • Very good
10

MENTAL HEALTH

Please answer as the following questions as best you can.

MENTAL HEALTH ASSESSMENTS

GAD-7 ANXIETY

Please select one answer for each question
  • Choose
  • Not at all
  • Several days
  • More than half the days
  • Nearly every day
  • Choose
  • Not at all
  • Several days
  • More than half the days
  • Nearly every day
  • Choose
  • Not at all
  • Several days
  • More than half the days
  • Nearly every day
  • Choose
  • Not at all
  • Several days
  • More than half the days
  • Nearly every day
  • Choose
  • Not at all
  • Several days
  • More than half the days
  • Nearly every day
  • Choose
  • Not at all
  • Several days
  • More than half the days
  • Nearly every day
  • Choose
  • Not at all
  • Several days
  • More than half the days
  • Nearly every day
  • Choose
  • Not difficult at all
  • Somewhat difficult
  • Very difficult
  • Extremely difficult

PHQ-9 DEPRESSION

Please select one answer for each question
  • Choose
  • Not at all
  • Several days
  • More than half the days
  • Nearly every day
  • Choose
  • Not at all
  • Several days
  • More than half the days
  • Nearly every day
  • Choose
  • Not at all
  • Several days
  • More than half the days
  • Nearly every day
  • Choose
  • Not at all
  • Several days
  • More than half the days
  • Nearly every day
  • Choose
  • Not at all
  • Several days
  • More than half the days
  • Nearly every day
  • Choose
  • Not at all
  • Several days
  • More than half the days
  • Nearly every day
  • Choose
  • Not at all
  • Several days
  • More than half the days
  • Nearly every day
  • Choose
  • Not at all
  • Several days
  • More than half the days
  • Nearly every day
  • Choose
  • Not at all
  • Several days
  • More than half the days
  • Nearly every day

WORK AND SOCIAL ADJUSTMENT SCALE (WSAS)

Please Select One Answer For Each Question

 

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.
  • Choose
  • 0. Not at all
  • 1.
  • 2. Slightly
  • 3.
  • 4. Definitely
  • 5.
  • 6. Markedly
  • 7.
  • 8. Very severly
  • Choose
  • 0. Not at all
  • 1.
  • 2. Slightly
  • 3.
  • 4. Definitely
  • 5.
  • 6. Markedly
  • 7.
  • 8. Very severely
  • Choose
  • 0. Not at all
  • 1.
  • 2. Slightly
  • 3.
  • 4. Definitely
  • 5.
  • 6. Markedly
  • 7.
  • 8. Very severely
  • Choose
  • 0. Not at all
  • 1.
  • 2. Slightly
  • 3.
  • 4. Definitely
  • 5.
  • 6. Markedly
  • 7.
  • 8. Very severely
  • Choose
  • 0. Not at all
  • 1.
  • 2. Slightly
  • 3.
  • 4. Definitely
  • 5.
  • 6. Markedly
  • 7.
  • 8. Very severely

ADDITIONAL INFORMATION

  • Choose
  • GP
  • Psychologist
  • Psychiatrist
  • Friend
  • Combat Stress
  • Help for Heroes
  • RBL
  • SSAFA
  • Legion Scotland
  • The Veterans Charity
  • Project Nova
  • Helping Homeless Veterans-UK
  • Other
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