Road Traffic Questionnaire Road Traffic Questionnaire Address & Contact Your Name? * PostCode? * Date of birth? * You would like? Pay-Privately Pay-Privately to Start & NHS Application NHS Application Employer Support Legal Referral OtherOther NHS Application NHS Funding Application’s are based on your exceptional circumstances. NHS Applications can take up to 12 weeks to get a decision. Pay Privately & NHS Application Paying privately allows you to start counselling quickly. When this form is completed, we will arrange your counselling. Fees Introduction Session £50 Pay-as-you-go £70 Saver3 (3 sessions) £180 NHS Application’s rate of success depends on your location. The standard timescales are eight weeks from when your GP sends our application to the funding panel. Pay Privately Paying privately allows you to start counselling quickly. When this form is completed, we will arrange your counselling. Fees Introduction Session £50 Pay-as-you-go £70 Saver3 (3 sessions) £180 Section Buttons Doctor Details Surgery Name Postcode Doctors email address Only used for NHS funding application Dr Name (if Known) Section Buttons Home? Relationship? Single Divorced Live-In-Partner Married Any, children at home? Yes No Children you care for Section Buttons Employment? Employed? Yes No Status Full-Time Part-Time Are You Medically or Physically Able to Work? Yes No OtherOther Are You Retired? Yes No Are you a student? Yes No Section Buttons Aspirations from 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 Section Buttons Next RTA You were? Driver Passenger Witness OtherOther What Injuries or Disabilities do you or did you have? Can you briefly describe the accident? How has the accident affected you? Try and explain how your life has changed since the accident. Prior to the accident did you have any mental health issues? Section Buttons Health Do you use a mobility device? Not Needed Crutches Wheelchair User Motorised Wheelchair Supporting Frame OtherOther Medication? None Antidepressants Antipsychotics Anti-Anxiety Heart Medication Diabetes Medication Mood Stabilisers Stimulants OtherOther Any, medical issues? Alzheimers Arthritis Asthma Blood Pressure Cancer Infectious Disease Lung Conditions Diabetes Heart Issues Stroke OtherOther Anything to add Medically? Section Buttons Next 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 OtherOther Section Buttons Pain Do you have daily chronic pain? No Yes OtherOther Do you have aches and pains in your joints or body? No Yes OtherOther Do you have muscle cramps & spasms? No Yes OtherOther Are the muscle cramps or spasms painful? No Yes OtherOther Section Buttons Any, Additional Disabilities Do you have any additional disabilities? Ataxia Autism Epilepsy Hearing Loss Medical Illness MS Sight Loss Spinal Injury Nerological Problems OtherOther Hearing Loss Mild Moderate Severe Deaf/BSL User OtherOther Sight Loss Mild Moderate Severe Blind OtherOther Spinal Injury Complete Incomplete OtherOther Epilepsy Type? Absence Clonic Focal Generalised Tonic-Clonic OtherOther Absence Absence seizures are more common in children than adults and can happen very frequently. During an absence a person becomes unconscious for a short time. They may look blank and stare, or their eyelids might flutter. They will not respond to what is happening around them. If they are walking they may carry on walking but will not be aware of what they are doing. Clonic Clonic seizures involve repeated rhythmical jerking movements of one side or part of the body or both sides (the whole body) depending on where the seizure starts. Seizures can start in one part of the brain (called focal motor) or affect both sides of the brain (called generalised clonic). Focal As the seizure progresses, a person can experience motor and non-motor symptoms. Some motor symptoms of focal seizures include: muscle twitching jerking spasms repeated movements, like clapping or chewing Non-motor symptoms do not affect how someone moves. However, they may cause confusion or changes in emotions. Some non-motor symptoms of focal seizures include: waves of hot or cold goosebumps lack of movement changes in emotions or thoughts Generalised Generalised onset seizures affect both sides of the brain at once and happen without warning. The person will be unconscious (except in myoclonic seizures), even if just for a few seconds and afterwards will not remember what happened during the seizure. Unknown onset seizures are sometimes used to describe a seizure if doctors are not sure where in the brain the seizure starts. This may happen if the person was asleep, alone or the seizure was not witnessed. If there is not enough information about a person’s seizure, or if it is unusual, doctors may call it an unclassified seizure. Tonic Clonic These are the seizures that most people think of as epilepsy. The person becomes unconscious their body goes stiff and if they are standing up they usually fall backwards. They jerk and shake as their muscles relax and tighten rhythmically. Other Epilepsy Best describe what other Epilepsy is What medical illness? What is the neurological problem? What is the other? Section Buttons Next NHS Past Counselling? Any, Past Counselling? * Yes No What Year? Approx How many sessions? Approx Any other NHS sessions ? No Yes What Year? Approx How many sessions? Approx Any other NHS sessions?? No Yes Details on how many and year approx Experience of NHS Counselling Good Did not understand my disability No experience supporting RTA Poor OtherOther Section Buttons Any other counselling? What other counselling No Self-paid Employer provided School or university Insurance Profesional organisation OtherOther Could you add the approx year & how many sessions? Section Buttons Brief Summary Would you like to add anything? Section Buttons Submit