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Downs Syndrome Questionaire
Complex Care Counselling
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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
Other
Other
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
Other
Other
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
Other
Other
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