Downs Syndrome Questionaire Downs Questionnaire Who is completing this form? If person plus another, please select each one who is completing the form Please tell us who is completing the form? Person who wants counselling Carer Mother/Father Family memeber Social services OtherOther Person who wants counselling Name? * PostCode? * GP Details Surgery Name Postcode Dr Name (if Known) Home? Relationship? Single Divorced Live-In-Partner Married Children? Yes No Employment? Employed? Yes No Status Full-Time Part-Time Medically or Physically Able to Work? Yes No OtherOther Retired? Yes No Student? Yes No Aspirations? What is the aim of counselling? 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 OtherOther Next