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General Disabilities Self-Paid Questionnaire
Confidentiality
Read Privacy Statement
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Yes
No
Privacy Statement
All information entered on this form is private and confidential. As a mental health service, we prioritise your privacy and the confidentiality of your personal and health information. The details you provide will only be used to support your care and treatment and will not be shared with any third parties without your explicit consent. Your trust is important to us, and we are committed to protecting your privacy in accordance with applicable privacy laws and professional standards.
Address & Contact
Your Name?
*
PostCode?
*
Date of Birth
*
Headline Disability or Topic
*
What Would You Like Help With?
Multi-Select Available
Addictions
Anger
Anxiety
Body Dysmorphia
Chronic Fatigue Syndrome
Chronic Pain
Depression
Dissociative Disorders
Health Anxiety
Fibromyalgia
OCD
Continued
Psychosis
Panic Disorder
Personality Disorder
Phobias
PTSD
Social Anxiety
Stress
Suicidal Thought
Self-Harm Thoughts
Other
Other
Assistive Devices
Mobility Device?
*
Not Needed
Crutches
Supporting frame
Tilt-in-space
Manuel wheelchair
Standing wheelchair
Motorised wheelchair
Standing frame
Other
Other
Assistive Technology?
*
Not Needed
Electronic communication board
Low-tech communication board
Speech-generating device
Eye-tracking device
Typing and writing devices
Hearing Aids
Cochlear Implant
Other
Other
Multi-select
Disability, Injury or Issue?
Do you have a medical health problems?
No
Yes
What is your medical problem? (multi-select)
Alzheimers
Arthritis
Asthma
Blood Pressure
Cancer
Infectious Disease
Lung Conditions
Diabetes
Heart Issues
Stroke
Other
Other
Do you take medication?
None
Antidepressants
Antipsychotics
Anti-Anxiety
Heart Medication
Diabetes Medication
Mood Stabilisers
Stimulants
Other
Other
Please write a brief outline of your medical problem
Is your problem related to food?
No
Yes
Please write a brief outline of your food problem
Is your problem related to addictions?
No
Yes
Please write a brief outline of your addictions problem
Is your problem related to phobias?
No
Yes
Please write a brief outline of your phobia problem
Is your problem related to a Injury?
No
Yes
Please write a brief outline of your injury problem
Is your problem related to a neurological issue?
No
Yes
Please write a brief outline of your neurological problem
Is your problem related to sudden or progressive hearing loss?
No
Yes
Please write a brief outline of how the hearing loss started and in which or both ears.
Do you have tinnitus?
No
Yes
Please write a brief outline of how the tinnitus effects you, ie which ear etc
Is your problem related to assault?
No
Yes
Please write in type of assault (not details of the assault)
Please insert type of assault
Is your problem related to trauma?
No
Yes
Please explain how the trauma affects you?
Is your problem related to epilepsy?
No
Yes
Please explain frequency and type of epilepsy
Is your problem related to chronic pain?
No
Yes
Please write in type and effects of chronic pain
Do you have any of these conditions?
Please Select? Multi-select available
No
Learning Difficulties (general)
Autism/Aspergers
Fragile x
Developmental Delay
Challenging Behaviours
Other
Other
Have you been diagnosed by GP or other medical professional?
If yes, When and who by? also how Autism affects you?
Legal
Are you in dispute with any authorities or persons?
No
Person
NHS
Employer
Organisation
Other
Other
Is your dispute going to court or litigation?
No
Yes
Other
Other
Briefly explain the dispute.
Briefly explain at what stage you are at with the courts or litigation and any possible timelines.
Employment
Are you medically or physically able to work?
Yes
No
Other
Other
Carer Questions?
Do you have a carer?
No
Yes
Other
Other
Is you carer?
Parent
Partner
Social Services
Other
Other
Carer hours?
1-4 hours daily
5 – 8 hours daily
Live-in
Assisted living at home
Assisted living (social services)
Other
Other
Anything to add about carer?
If you are human, leave this field blank.
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