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Complex Care Counselling
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General Questionaire
Autism Client Questionnaire
You are?
First Name?
*
Surname Name ?
*
Date of Birth?
*
Relationship
Single
Divorced
Live-in-Partner
Married
Other
Other
Children under 18?
Yes
No
Other
Other
How many children?
Employed?
Yes
No
Other
Other
Vocation?
Carer
University
Retired
Other
Other
Do you have a Carer?
Yes
No
Other
Other
Who Carer?
Parents
Extended Family
Partner
Social Services
Other
Other
How many hours per day?
Service?
What service would you like?
NHS Application
Self-Pay
Self pay to start & NHS Application
Medication?
Do you take medication?
Yes
No
Other
Other
What medication do you take?
Any Medical Issues?
Have you got any medical conditions?
Yes
No
Other
Other
What medical conditions?
Social Settings?
Do you feel anxious in public?
Yes
Sometimes
No
Other
Other
Do you lack support in the ways you need from family or close friends?
Yes
Sometimes
No
Other
Other
Do you feel ignored by people?
Yes
Sometimes
No
Other
Other
Do you lack support in the ways you need from your partner or spouse?
Yes
Sometimes
No
Other
Other
Do you feel worried about people’s reactions to you?
Yes
Sometimes
No
Other
Other
Do you feel shamed in public?
Yes
Sometimes
No
Other
Other
Do you feel confined to the house more than you would like?
Yes
Sometimes
No
Other
Other
Do you feel you must conceal your disability from people
Yes
Sometimes
No
Other
Other
Does disability affect your close personal relationships?
Yes
Sometimes
No
Other
Other
Do you feel people try and take away your independence by over sympathising
Yes
Sometimes
No
Other
Other
Do you feel embarrassed in public?
Yes
Sometimes
No
Other
Other
If you are human, leave this field blank.
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