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Sight Loss Referral
Questionnaire?
What is the referral for?
NHS Application
Self-Pay
NHS application + self-pay for quick start
Other
Other
If self-pay, which plan?
Not sure
Introduction Session £50
Pay per session £70
Buy block of 3 sessions £180 (£60)
Other
Other
Preference? (multi-select)
Video Sessions
Telephone
Jointly Video & Phone
Other
Other
Aspirations from counselling?
Facilitating behaviour change
Enhancing coping skills
Facilitating your potential
Development of self-worth
Improving relationships
Reduce anger
Reduce negative feeling and thoughts
Explore broad set of issues
Reduce or remove addictions
Establish and maintain relationships
Remove or reduce negative cycles
Other
Other
Address & Contact
Your Name?
PostCode?
Date of Birth?
Phone Number
Email
Gender?
GP Details
Surgery Name
Dr Name (if Known)
Postcode
Home?
Relationship?
Single
Divorced
Live-In-Partner
Married
Other
Have you got a carer?
Not needed
Yes – Part-Time
Yes – Full-Time
No – but need one
Employment?
Employed?
Yes
No
Status
Full-Time
Part-Time
Are You Medically or Physically Able to Work?
Yes
No
Other
Other
Your Vision?
Vision Scale
Blind (100%)
Blind (80% & Over)
Sight Loss (50% & Over)
Vision Impaired (30% & Over)
Poor Vision (up to 30%)
Vision?
One eye
Both eyes
Reasoning?
From Birth
Gradual Reducing Eye Sight
Unexplained (Sudden Acquired)
Trauma (Sudden Acquired)
Medical
Do you feel your vision loss is the basis of your mental health issues?
No
Yes
Partly
Mobility
Mobility Device?
Not needed
Walking stick
Guide dog
Both walking stick & guide dog
Wheelchair user
Motorised wheelchair
Supporting frame
Other
Other
Medical
Medication? (multi-select if needed)
None
Antidepressants
Antipsychotics
Anti-Anxiety
Heart Medication
Diabetes Medication
Mood Stabilisers
Stimulants
Other
Other
Any Medical Issues?
Yes
No
What? (multi-select)
Alzheimers
Arthritis
Asthma
Blood Pressure
Cancer
Infectious Disease
Lung Conditions
Diabetes
Neurological Issues
Eyesight Problems
Hearing/Ear
Heart Issues
Stroke
Other
Other
Anything to add Medically?
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
Past Counselling?
Any, Past Counselling?
Yes
No
How Were They Funded?
NHS
RNIB
Employment Support
Self-Paid
Other
Other
Approx When?
This year
Last year
within last 5 years
6 years or more ago
Approx Number of Sessions
Brief Summary
Please explain as briefly as possible what your current issues are?
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