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Complex Care Counselling
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CP Referral & Questionnaire
CP Questionnaire & Referral
Who is completing this form?
Please tell us who is completing the form?
Myself
Carer
Mother/Father
Family memeber
Social services
Other
Other
If one or more people are completing this form multi-select from the answers above.
Address & Contact
Your Initials?
*
Postcode?
*
Date of Birth
Home?
Relationship?
Single
Divorced
Live-In-Partner
Married
Children?
Yes
No
Employment?
Employed?
Yes
No
Status
Full-Time
Part-Time
Are You Medically or Physically Able to Work?
Yes
No
Other
Other
Are You Retired?
Yes
No
Are you a student?
Yes
No
GP Details
Surgery Name
*
Postcode or Town
*
Dr Name (if Known)
Health
Medication?
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
Heart Issues
Stroke
Other
Other
Anything to add Medically?
Aspirations?
Multi-select
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
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
If you are human, leave this field blank.
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