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Self Referral
Free Funding Self-Referral All
The Form?
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General
How did you find us?
Internet Search
Social Media
NHS Referral
Recommendation
MS-UK
Other Organisation – Please tell us who
Other Organisation – Please tell us who
How would you like to be contacted?
Email
Text
Phone
Other
Other
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Sessions?
What is the referral for?
NHS Application
Self-Pay
Self-Pay to Start & NHS Application
Other
Other
Preference?
Video Sessions
Telephone
Other
Other
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Aspirations?
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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Address & Contact
Your Name?
PostCode?
Date of Birth
Phone Number
Email
Gender
Male
Female
Other
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Gender
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GP Details
Surgery Name
Postcode
Dr Name (if Known)
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Home?
Relationship?
Single
Divorced
Live-In-Partner
Married
Children?
Yes
No
Have you got a carer?
Yes – Full-Time
Yes – Part-Time
No
Do they live with you?
Live-at-Home
Adult (my full-time carer)
Now Adults (left home)
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Employment?
Employed?
Yes
No
Status
Full-Time
Part-Time
Are You Medically or Physically Able to Work?
Yes
No
Other
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Are You Medically or Physically Able to Work?
Are You Retired?
Yes
No
Are You A Carer?
Yes
No
Are you a student?
Yes
No
Section Buttons
Select Therapy
Your Counselling Topic?
*
Autism
Brittle Bones
BSL Therapy
Hearing Loss
Carer
Cerebral Palsy
Chronic Pain
Cochlear
Down's Syndrome
CODA
Dystrophy
Dwarfism
Dyslexia
Epilepsy
Head Injury
Limb Loss
Lumber Spondylosis
Multiple Sclerosis
Mutism
Parkinson's
Road Traffic Accident
Relationships
Skeletal Dysplasia
Spina Bifida
Spinal Cord Injury
Sight Loss
Tinnitus
Vestibular
Other
What?
Section Buttons
Next
Down’s Syndrome Questions
Down’s Syndrome Type
Trisomy 21
Translocation Down syndrome
Mosaic Down syndrome
Other
Other
Any Other Related Health Problems?
Asthma
Childhood leukemia
Hearing loss
Ear infections
Early-onset dementia
Gastrointestinal disorders
Heart defects
Pulmonary hypertension
Obstructive sleep apnea
Vision problems
Underactive thyroid
Seizures
Other
Other
Multi-Select if needed
Asthma severity
Mild
Moderate
Severe
Other
Other
Hearing loss severity
Mild
Moderate
Severe
Other
Other
Vision loss severity
Mild
Moderate
Severe
Other
Other
Seizures (average)
Daily
Weekly
Monthly
Other
Other
Sleep Apnea severity
Mild
Moderate
Severe
Other
Other
Other severity
Mild
Moderate
Severe
Other
Other
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Mood Assessment
Are your relationships intense, and unstable, and alternate between the extremes of over-idealising and undervaluing people who are important to you?
No
Sometimes
Mostly
Other
Other
Do your emotions change quickly, and you experience intense episodes of sadness, irritability, and anxiety or panic attacks?
No
Sometimes
Mostly
Other
Other
Do you engage in recurrent suicidal behaviours, gestures, threats, or self-injurious behaviour such as cutting, burning, or hitting?
No
Sometimes
Mostly
Other
Other
Is your level of anger often inappropriate, intense, and challenging to control.
No
Sometimes
Mostly
Other
Other
Have you a persistent unstable image or sense of self, or of who or what you believe in?
No
Sometimes
Mostly
Other
Other
Do you have suspicious ideas, or paranoia ( believing that others are plotting to cause you harm)?
No
Sometimes
Mostly
Other
Other
Do you experience under stress episodes that other people, or the situation is somewhat unreal
No
Sometimes
Mostly
Other
Other
Do you engage in frantic efforts to avoid real or imagined abandonment by people who are close to you?
No
Sometimes
Mostly
Other
Other
Now or in the past, engage in two or more self-damaging acts such as inappropriate sexual conduct, substance abuse, reckless driving, and binge eating
No
Sometimes
Mostly
Other
Other
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Loss of Limb Questions?
Carer for person who is or has?
Autistic
Brittle Bones
Deaf
Hearing Loss
Cerebral Palsy
Chronic Pain
Cochlear
CODA
Dystrophy
Dyslexia
Epilepsy
Limb Loss
Multiple Sclerosis
Parkinson's
Road Traffic Accident
Spina Bifida
Spinal Cord Injury
Sight Loss
Tinnitus
Vestibular
Status?
Pre-Amputation
New Amputation
Long Term Amputee
Other
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Status?
Are you a Carer for
Adult (partner)
Adult (son/daughter)
Adult (extended family)
Adult (profesional organisation)
My son or daughter (0-12)
My son or daughter (13-18)
Child (0-12)
Teenager (13-18)
Other
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Are you a Carer for
Type of amputation?
Leg (below knee)
Leg (above knee)
One Arm
Both Arms
One Hand
Both Hands
How?
Planned Medical Procedure
Medical Negligence
Road Traffic Accident
Personal Injury at Work
Leisure Activity
Other
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How?
Mobility Device?
*
Not Needed
Crutches
Wheelchair User
Motorised Wheelchair
Supporting Frame
Other
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Mobility Device?
Medication?
None
Antidepressants
Antipsychotics
Anti-Anxiety
Heart Medication
Diabetes Medication
Mood Stabilisers
Stimulants
Other
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Medication?
Any Other Medical Issues?
*
No
Yes
What? (multi-select)
Alzheimers
Arthritis
Asthma
Blood Pressure
Cancer
Infectious Disease
Lung Conditions
Diabetes
Neurological Issues
Eyesight Problems
Hearing/Ear
Heart Issues
Stroke
Other
Other
Anything to add Medically?
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Road Traffic Accident Questions?
What year was the accident?
Were you the driver?
Yes
Passenger
Other
Other
From the accident?
PTSD
Trauma
Nervousness
Despondency
Vulnerability
Fear of getting into a car
Fear of using public transport
Other
Other
Multi- Select if required
Is or was there a court case?
No
Yes (ongoing)
Yes (finished)
Other
Other
Do you require a report
Yes – Solicitor has asked
Yes – Court has asked
Other
Other
Did you receive a life changing injury?
None
Amputation
Spinal cord injury
Body disfigurement
Epilepsy
Other
Other
Multi-select (if required)
What stage of Amputee?
Pre-Amputation
New Amputation
Long Term Amputee
Other
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What stage of Amputee?
Type of amputation?
Leg (below knee)
Leg (above knee)
One Arm
Both Arms
One Hand
Both Hands
What type of disfigurement?
Face
Head
Arms
Legs
Back
Chest
Other
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What type of disfigurement?
Short summary of the disfigurement?
Spinal cord injury classed as?
Paraplegia
Quadriplegia
Body Effects?
Muscle Movement Difficulties or Loss
Low or No Reflexes
Low or No Sensations
Other
Other
Complications?
Bladder & Bowel Functions
Breathing Issues
Increase or Decrease of Heart Rate
Metabolism Deficiencies
Type of Seizure?
Complex partial (focal)
Tonic-clonic seizures
Absences
Myoclonic seizures
Clonic seizures
Tonic seizures
Atonic seizures
Status epilepticus
Frequency of Seizure?
Daily
2 or 3 times a week
4 or 6 times a week
Weekly
Monthly
Periodic (no frequency)
Mobility Device?
*
Not Needed
Crutches
Wheelchair User
Motorised Wheelchair
Supporting Frame
Other
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Mobility Device?
Medication?
None
Antidepressants
Antipsychotics
Anti-Anxiety
Heart Medication
Diabetes Medication
Mood Stabilisers
Stimulants
Other
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Medication?
Any Other Medical Issues?
Yes
No
What? (multi-select)
Alzheimers
Arthritis
Asthma
Blood Pressure
Cancer
Infectious Disease
Lung Conditions
Diabetes
Neurological Issues
Eyesight Problems
Hearing/Ear
Heart Issues
Stroke
Other
Other
Short Summary (other medical)
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Head Injury Questions?
Type of Head Injury
Concussion
Skull Fracture
Medical Event
Hypoxic Injury
Other
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Type of Head Injury
Cause?
Road Traffic Accident
Trip or Fall
Operation
Blood Clot
Act of Violence
Cerebral Anoxia
Other
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Cause?
Do you Know Type?
No
Epidural hematoma
Subdural hematoma
Contusion or intracerebral hematoma
Diffuse axonal injury (DAI)
Other
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Do you Know Type?
Skull Injury?
No Skull Injury
Linear skull fractures
Depressed skull fractures
Diastatic skull fractures
Basilar skull fracture
Other
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Skull Injury?
Linear skull fractures
This is the most common type of skull fracture. In a linear fracture, there is a break in the bone, but it does not move the bone. These patients may be observed in the hospital for a brief amount of time, and can usually resume normal activities in a few days. Usually, no interventions are necessary.
Depressed skull fractures
This type of fracture may be seen with or without a cut in the scalp. In this fracture, part of the skull is actually sunken in from the trauma. This type of skull fracture may require surgical intervention, depending on the severity, to help correct the deformity.
Diastatic skull fractures
These are fractures that occur along the suture lines in the skull. The sutures are the areas between the bones in the head that fuse when we are children. In this type of fracture, the normal suture lines are widened. These fractures are more often seen in newborns and older infants.
Basilar skull fracture
This is the most serious type of skull fracture, and involves a break in the bone at the base of the skull. Patients with this type of fracture frequently have bruises around their eyes and a bruise behind their ear. They may also have clear fluid draining from their nose or ears due to a tear in part of the covering of the brain. These patients usually require close observation in the hospital.
Epidural hematoma
Epidural hematomas occur when a blood clot forms underneath the skull, but on top of the dura, the tough covering that surrounds the brain. They usually come from a tear in an artery that runs just under the skull called the middle meningeal artery. Epidural hematomas are usually associated with a skull fracture.
Subdural hematoma
Subdural hematomas occur when a blood clot forms underneath the skull and underneath the dura, but outside of the brain. These can form from a tear in the veins that go from the brain to the dura, or from a cut on the brain itself. They are sometimes, but not always, associated with a skull fracture.
Contusion or intracerebral hematoma
A contusion is a bruise to the brain itself. A contusion causes bleeding and swelling inside of the brain around the area where the head was struck. Contusions may occur with skull fractures or other blood clots such as a subdural or epidural hematoma. Bleeding that occurs inside the brain itself (also called intraparenchymal hemorrhage) can sometimes occur spontaneously. When trauma is not the cause, the most common causes are long-standing, high blood pressure in older adults, bleeding disorders in either children or adults, or the use of medications that cause blood thinning or certain illicit drugs.
Diffuse axonal injury (DAI)
These injuries are fairly common and are usually caused by shaking of the brain back and forth, which can happen in car accidents, from falls or shaken baby syndrome. Diffuse injuries can be mild, such as with a concussion, or may be very severe, as in diffuse axonal injury (DAI). In DAI, the patient is usually in a coma for a prolonged period of time, with injury to many different parts of the brain.
Cause of Cerebral Anoxia
Cardiac or respiratory arrest
Irregular heart rhythm
heart attack
Low blood pressure
Suffocation
Choking
Strangulation
Asthma attack
General anaesthesia
Near drowning
Exposure to high altitudes
Smoke inhalation
Carbon monoxide inhalation
Poisoning
Drug overdose
Electric shock
Other
Other
Is or was there a court case?
No
Yes (ongoing)
Yes (finished)
Other
Other
Do you require a report
Yes – Solicitor has asked
Yes – Court has asked
Other
Other
Did you receive a life changing injury?
None
Amputation
Spinal cord injury
Body disfigurement
Epilepsy
Permanent Memory Loss
Temporary Memory Loss
Other
Other
Multi-select (if required)
What stage of Amputee?
Pre-Amputation
New Amputation
Long Term Amputee
Other
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What stage of Amputee?
Type of amputation?
Leg (below knee)
Leg (above knee)
One Arm
Both Arms
One Hand
Both Hands
Lasting effects of the brain injury
Headaches
Migranes
Sensitivity to noise and light
Irritability
Confusion
Lightheadedness and/or dizziness
Problems with balance
Nausea
Problems with concentration
Change in sleep patterns
Blurred vision
“Tired” eyes
Ringing in the ears (tinnitus)
Alteration in taste
Fatigue or lethargy
Slurred speech
Difficulty with walking
Weakness in one side or area of the body
Sweating
Pale skin colour
Other
Other
Please multi-select any of the symptoms and lasting affects of your brain injury.
Spinal cord injury classed as?
Paraplegia
Quadriplegia
Body Effects?
Muscle Movement Difficulties or Loss
Low or No Reflexes
Low or No Sensations
Other
Other
Complications?
Bladder & Bowel Functions
Breathing Issues
Increase or Decrease of Heart Rate
Metabolism Deficiencies
Type of Seizure?
Complex partial (focal)
Tonic-clonic seizures
Absences
Myoclonic seizures
Clonic seizures
Tonic seizures
Atonic seizures
Status epilepticus
Frequency of Seizure?
Daily
2 or 3 times a week
4 or 6 times a week
Weekly
Monthly
Periodic (no frequency)
Mobility Device?
*
Not Needed
Crutches
Wheelchair User
Motorised Wheelchair
Supporting Frame
Other
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Mobility Device?
Medication?
None
Antidepressants
Antipsychotics
Anti-Anxiety
Heart Medication
Diabetes Medication
Mood Stabilisers
Stimulants
Other
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Medication?
Any Other Medical Issues?
Yes
No
What? (multi-select)
Alzheimers
Arthritis
Asthma
Blood Pressure
Cancer
Infectious Disease
Lung Conditions
Diabetes
Neurological Issues
Eyesight Problems
Hearing/Ear
Heart Issues
Stroke
Other
Other
Short Summary (other medical)
Section Buttons
Spinal Cord Injury Questions?
How?
Act of Violence or Attack
Fall or Trip
Leisure Activity
Personal Injury at Work
Road Traffic Accident
Sports Injury
Surgical Complications
Other
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How?
Effect?
Paraplegia
Quadriplegia
Medication?
None
Antidepressants
Antipsychotics
Anti-Anxiety
Heart Medication
Diabetes Medication
Mood Stabilisers
Stimulants
Other
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Medication?
Complications?
Bladder & Bowel Functions
Breathing Issues
Increase or Decrease of Heart Rate
Metabolism Deficiencies
Body Effects?
Muscle Movement Difficulties or Loss
Low or No Reflexes
Low or No Sensations
Other
Other
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Lumber Spondylosis Questions?
Type of Lumbar Spondylosis
Traumatic
Iatrogenic
Congenital
Degenerative
Pathologic,
Isthmic
Other
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Type of Lumbar Spondylosis
Other – Spondylolisthesis
Please us know your symptoms the best you can.
Congenital/Dysplastic
Congenital spondylolisthesis, also known as dysplastic spondylolisthesis, is an abnormality present at birth. The slip in this type of spondylolisthesis is a defect in the facet joints which connect spinal vertebrae. This occurs in the lower joints at L5 (inferior joint), the upper joints at S1 (superior joints), or at both joints and causes a gradual slip of the L5 vertebrae over time. This type of spondylolisthesis is rare compared to the other types.
Isthmic
Isthmic spondylolisthesis is the most common type of spondylolisthesis and is divided into three separate subtypes, but all have a defect at the same location in the spine. In isthmic spondylolisthesis there is a defect, typically a fracture, of the pars interarticularis, the bone that connects the upper and lower facet joints. This fracture prevents the affected vertebra from staying in line with the other vertebrae, allowing it to slide forward. The L5-S1 level is most frequently affected by isthmic spondylolisthesis.
Degenerative
Degenerative spondylolisthesis is a slip from arthritis within the spine. Degenerative changes or arthritis is common in aging individuals. Once the joints in the spine begin to wear, they have difficulty keeping the spine in line and a vertebra slips forward. This occurs most frequently in the lumbar spine, but can happen in the cervical spine as well.
Traumatic
Traumatic spondylolisthesis is a slip due to an event that places a large amount of force on the spine. This high force results in damage to the neural arch, which is the ring of bone that surrounds the spinal cord. The fracture of the neural arch causes a sliding forward of the vertebrae. Both the cervical and lumbar spine may be affected, but this is an uncommon type of spondylolisthesis.
Pathologic
Pathologic spondylolisthesis is a slip from weakness within the bones, such as tumors, types of cancers, and bone disease. This weakening causes destruction of the posterior (backside) portion of the vertebrae, such as the neural arch, which surrounds the spinal cord. Just like the traumatic type, pathologic spondylolisthesis is a rare type.
Iatrogenic
Iatrogenic Iatrogenic spondylolisthesis is a slip caused directly from a prior spine surgery that involved decompression of the spine without stabilization. During decompression procedure a small amount of bone is removed to release pressure on the spinal cord and/or the nerves that branch off. The removal of too much bone during this procedure can cause the vertebral body to slip. In general, this is avoided using a stabilization surgery when a large portion of bone needs to be removed.
How?
Act of Violence or Attack
Age Related
Fall or Trip
Leisure Activity
Genetic Condition
Personal Injury at Work
Road Traffic Accident
Sports Injury
Surgical Complications
Other
How?
Effect?
Paraplegia
Quadriplegia
Reduced Mobility
Chronic Pain
Medication?
None
Antidepressants
Antipsychotics
Anti-Anxiety
Heart Medication
Diabetes Medication
Mood Stabilisers
Stimulants
Other
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Medication?
Complications?
Bladder & Bowel Functions
Breathing Issues
Increase or Decrease of Heart Rate
Metabolism Deficiencies
Body Effects?
Muscle Movement Difficulties or Loss
Low or No Reflexes
Low or No Sensations
Other
Other
Section Buttons
Health (SCI)
Any Medical Issues?
Yes
No
Mobility Device?
Not Needed
Crutches
Manuel Wheelchair User
Motorised Wheelchair
Supporting Frame
Other
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Mobility Device?
Other Medications?
None
Antidepressants
Antipsychotics
Anti-Anxiety
Heart Medication
Diabetes Medication
Mood Stabilisers
Stimulants
Other
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Other Medications?
What? (multi-select)
Alzheimers
Arthritis
Asthma
Blood Pressure
Cancer
Infectious Disease
Lung Conditions
Diabetes
Neurological Issues
Eyesight Problems
Hearing & Ear Problems
Heart Issues
Stroke
Other
Other
Anything to add Medically?
Section Buttons
Epilepsy Questions?
Type of Seizure?
Complex partial (focal)
Tonic-clonic seizures
Absences
Myoclonic seizures
Clonic seizures
Tonic seizures
Atonic seizures
Status epilepticus
When did your Epilepsy start (year)
NHS Application?
Yes
No
Please confirm you would like us to make an NHS application for you.
Free Funding
DisabilityPlus can apply for NHS funding for you based on exceptional circumstances. To qualify for an application you would need to show symptoms such as 3 or more Tonic-Clonic (grand mal) seizures per week or are Status Epilepticus. (no NHS application is pre-approved by the NHS, we do though support many regions in the UK) If you do not qualify for an NHS application for free funding with DisabilityPlus, we can offer self-paid plans, please continue if you would like to self-pay. Or If you would still like NHS free funded sessions please contact your GP for free counselling with your local mental health services.
Self-Pay Plans
We can offer self-pay plans, this will enable you to start therapy quickly. Pricing: Introduction Session – £50 Single Sessions – £70 3 Session Saver – £180 (£60)
Medications?
None
Acetazolamide
Briviact
Carbamazepine
Cenobamate
Clobazam
Clonazepam
Eslicarbazepine acetate
Ethosuximide
Everolimus
Fenfluramine
Gabapentin
Lacosamide
Lamotrigine
Levetiracetam
Oxcarbazepine
Perampanel
Phenobarbital
Phenytoin
Piracetam
Pregabalin
Primidone
Rufinamide
Sodium valproate
Stiripentol
Tiagabine
Topiramate
Valproic acid
Vigabatrin
Zonisamide
Other
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Medications?
Other Medications? (generalised)
None
Antidepressants
Anti-Anxiety Medications
Stimulants
Antipsychotics
Mood Stabilizers
Other
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Other Medications? (generalised)
Triggers? (multi-select if required)
Unexplained
Stress
Lack of sleep
Waking up
Flashing lights
Following a seizure?
No issues
Inconsistant thinking
Memory loss
Jumbled speech
Low attention span
Other
Other
Frequency (average based on a average week)
1
2
3
4
5
6
Other
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Frequency (average based on a average week)
Section Buttons
Seizure Classified as
Complex partial (focal)
During a complex partial seizure, you lose your sense of awareness and make random body movements, such as: • smacking your lips, rubbing your hands • making random noises • moving your arms around • picking at clothes or fiddling with objects • chewing or swallowing • You will not be able to respond to anyone else during the seizure and will not have any memory of it.
Clonic seizures
Clonic seizures cause the body to shake and jerk like a tonic-clonic seizure, but you do not go stiff at the start. They typically last a few minutes and you might lose consciousness.
Absences
An absence seizure, which used to be called a “petit mal”, is where you lose awareness of your surroundings for a short time. They mainly affect children but can happen at any age. During an absence seizure, a person may: • stare blankly into space • look like they’re “daydreaming.” • flutter their eyes • make slight jerking movements of their body or limbs • The seizures usually only last up to 15 seconds and you will not be able to remember them. They can happen several times a day.
Tonic-clonic
What happens during a tonic-clonic seizure? There are 2 phases in a tonic-clonic seizure: the ‘tonic’ phase, followed by the ‘clonic’ phase. During the tonic phase: • You lose consciousness, so you won’t be aware of what’s happening • All your muscles go stiff, and if you’re standing, you fall to the floor • Air might push past your voice box, which can make a sound like you’re crying out • You may bite down on your tongue or inside your mouth During the clonic phase: • Your limbs jerk quickly and rhythmically • You may lose control of your bladder and/or bowels • Your breathing may be affected, causing a blue tinge around your mouth
Atonic seizures
Atonic seizures cause all your muscles to suddenly relax, so you may fall to the ground. They tend to be very brief and you’ll usually be able to get up again straight away.
Status epilepticus
What Is Status Epilepticus? Status epilepticus is said to occur when a seizure lasts too long or when attacks occur close together and the person doesn’t recover between seizures. Just like there are different types of seizures, there are also different types of status epilepticus. Status Epilepticus? – defined as any seizure greater than 5 minutes. The longer a seizure lasts, the less likely it will stop on its own without medication.
Tonic seizures
Tonic seizures cause all your muscles to suddenly become stiff, like the first stage of a tonic-clonic seizure. This might mean you lose balance and fall over.
Myoclonic seizures
A myoclonic seizure is where some or all of your body suddenly twitches or jerks, like you’ve had an electric shock. They often happen soon after waking up. Myoclonic seizures usually only last a fraction of a second, but several can sometimes occur in a short space of time. You normally remain awake during them.
Does the classification match you?
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Cerebral Palsy Questions?
Cause?
Damage to part of the brain
Infection caught by parent
Stroke
Other
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Cause?
Any Mobility Devices?
Not Needed
Crutches
Manuel Wheelchair
Motorised Wheelchair
Supporting Frame
Other
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Any Mobility Devices?
Medication?
None
Antidepressants
Antipsychotics
Anti-Anxiety
Heart Medication
Diabetes Medication
Mood Stabilisers
Stimulants
Other
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Medication?
Assistance Devices?
Electronic communication boards
Eye-tracking devices
Assistive hearing devices
Adaptive writing and typing aids
Typing aids
Daily task assistive devices
Conditions (multiple selections)
Difficulty Walking
Muscle tone variations
Spasticity
Ataxia
Tremors
Favour one side of the body
Continued
Speech delay
Difficulty speaking
Seizures
Blindness
Neuro Diversity
Other
Other
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CP Epilepsy Questions?
Type of Seizure?
Complex partial (focal)
Tonic-clonic seizures
Absences
Myoclonic seizures
Clonic seizures
Tonic seizures
Atonic seizures
Status epilepticus
Frequency (average based on a average week)
1
2
3
4
5
6
Other
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Frequency (average based on a average week)
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Seizure Classified as
Complex partial (focal)
During a complex partial seizure, you lose your sense of awareness and make random body movements, such as: • smacking your lips, rubbing your hands • making random noises • moving your arms around • picking at clothes or fiddling with objects • chewing or swallowing • You will not be able to respond to anyone else during the seizure and will not have any memory of it.
Clonic seizures
Clonic seizures cause the body to shake and jerk like a tonic-clonic seizure, but you do not go stiff at the start. They typically last a few minutes and you might lose consciousness.
Absences
An absence seizure, which used to be called a “petit mal”, is where you lose awareness of your surroundings for a short time. They mainly affect children but can happen at any age. During an absence seizure, a person may: • stare blankly into space • look like they’re “daydreaming.” • flutter their eyes • make slight jerking movements of their body or limbs • The seizures usually only last up to 15 seconds and you will not be able to remember them. They can happen several times a day.
Tonic-clonic
What happens during a tonic-clonic seizure? There are 2 phases in a tonic-clonic seizure: the ‘tonic’ phase, followed by the ‘clonic’ phase. During the tonic phase: • You lose consciousness, so you won’t be aware of what’s happening • All your muscles go stiff, and if you’re standing, you fall to the floor • Air might push past your voice box, which can make a sound like you’re crying out • You may bite down on your tongue or inside your mouth During the clonic phase: • Your limbs jerk quickly and rhythmically • You may lose control of your bladder and/or bowels • Your breathing may be affected, causing a blue tinge around your mouth
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Atonic seizures
Atonic seizures cause all your muscles to suddenly relax, so you may fall to the ground. They tend to be very brief, and you’ll usually be able to get up again straight away.
Status epilepticus
What Is Status Epilepticus? Status epilepticus is said to occur when a seizure lasts too long or when attacks occur close together and the person doesn’t recover between seizures. Just like there are different types of seizures, there are also different types of status epilepticus. Status Epilepticus? – defined as any seizure greater than 5 minutes. The longer a seizure lasts, the less likely it will stop on its own without medication.
Tonic seizures
Tonic seizures cause all your muscles to suddenly become stiff, like the first stage of a tonic-clonic seizure. This might mean you lose balance and fall over.
Myoclonic seizures
A myoclonic seizure is where some or all of your body suddenly twitches or jerks, like you’ve had an electric shock. They often happen soon after waking up. Myoclonic seizures usually only last a fraction of a second, but several can sometimes occur in a short space of time. You normally remain awake during them.
Brittle Bones (OI) Questions?
Any, additional medical?
No
Yes
How?
Inherited
Spontaneous Mutation
Other
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How?
What? (multi-select)
Alzheimers
Arthritis
Asthma
Blood Pressure
Cancer
Infectious Disease
Lung Conditions
Diabetes
Neurological Issues
Eyesight Problems
Hearing & Ear Problems
Heart Issues
Stroke
Other
Other
Prognosis?
Mild
Moderate/Severe
Don't Know
Anything to add Medically?
Select Your Conditions? (Mild) (multi-select)
Few signs of the condition
Little to no bone deformity
Number of broken bones from a few to many
Height affected
Hearing Loss
Other
Other
Select Your Conditions? (Multi Select)
Increased number and frequency of broken bones
Problems with long bones slowly get worse
Short height
Abnormally shaped spine and rib cage
May have a dozen to several hundred broken bones in a lifetime
May not be able to move and may need a motorised wheelchair
Severe breathing problems
Other
Other
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Health
Mobility Device?
Not Required
Motorised Wheelchair
Manuel Wheelchair
Other
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Mobility Device?
Medications?
None
Antidepressants
Antipsychotics
Anti-Anxiety
Heart Medication
Diabetes Medication
Mood Stabilisers
Stimulants
Other
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Medications?
Any Medical Issues?
Yes
No
What? (multi-select)
Alzheimers
Arthritis
Asthma
Bisphosphonate
Blood Pressure
Cancer
Infectious Disease
Lung Conditions
Diabetes
Neurological Issues
Eyesight Problems
Hearing & Ear Problems
Heart Issues
Stroke
Other
Other
Anything to add Medically?
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Questions based on “you have or do you”?
Q1 – Little interest in doing things?
Never
Few Days
Most Days
Almost Every Day
Q2 – Feel down or depressed?
Never
Few Days
Most Days
Almost Every Day
Q3 -Have little sleep, or sleeping too much?
Never
Few Days
Most Days
Almost Every Day
Q4 -Feel tired or have little energy?
Never
Few Days
Most Days
Almost Every Day
Q5 – Poor appetite or overeating?
Never
Few Days
Most Days
Almost Every Day
Q6 -Feel bad about yourself or let family down?
Never
Few Days
Most Days
Almost Every Day
Q7 – Trouble concentrating on things?
Never
Few Days
Most Days
Almost Every Day
Q8 – Suicidal or self-harm thoughts?
Never
Few Days
Most Days
Almost Every Day
Q9 – Feel nervous, anxious or on edge?
Never
Few Days
Most Days
Almost Every Day
Q10 – Can you stop or control worrying?
Never
Few Days
Most Days
Almost Every Day
Q11 – Becoming easily annoyed or irritable?
Never
Few Days
Most Days
Almost Every Day
Q12 – Worry something awful might happen?
Never
Few Days
Most Days
Almost Every Day
Section Buttons
Daily Life Contributing Factors
Sliding scale – 1 low feeling moving up to 10 significant problem
Fearfull
0
1
2
3
4
5
6
7
8
9
10
Worried
0
1
2
3
4
5
6
7
8
9
10
Stressed
0
1
2
3
4
5
6
7
8
9
10
Irritable
0
1
2
3
4
5
6
7
8
9
10
Tiered
0
1
2
3
4
5
6
7
8
9
10
Sad
0
1
2
3
4
5
6
7
8
9
10
Jumbled thoughts
0
1
2
3
4
5
6
7
8
9
10
Confidence
0
1
2
3
4
5
6
7
8
9
10
Nausea
0
1
2
3
4
5
6
7
8
9
10
Headaches
0
1
2
3
4
5
6
7
8
9
10
Under-eating
0
1
2
3
4
5
6
7
8
9
10
Over-eating
0
1
2
3
4
5
6
7
8
9
10
Body image
0
1
2
3
4
5
6
7
8
9
10
Loss of control
0
1
2
3
4
5
6
7
8
9
10
Concentration
0
1
2
3
4
5
6
7
8
9
10
Dependance on others
0
1
2
3
4
5
6
7
8
9
10
Hot flushes
0
1
2
3
4
5
6
7
8
9
10
Neglected
0
1
2
3
4
5
6
7
8
9
10
Financial worry
0
1
2
3
4
5
6
7
8
9
10
Worried about future
0
1
2
3
4
5
6
7
8
9
10
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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
Relationships
Social Anxiety
Stress
Suicidal Thought
Self-Harm Thoughts
Other
Other
Section Buttons
Any, Significant Events
Multi-select if you require
None
Domestic Abuse
Physical Abuse
Emotional Abuse
Sexual Abuse
Victim of Violent Crime
Employment Issues
Addiction
Accident/Injury
Medical Issue
Long-Term Sickness
Court or Legal Proceedings
Other
Other
Section Buttons
Have You Ever Been Assessed & Diagnosed with?
Multi-select if you require
No
OCD
BPD
Schizophrenia
Hording
Bipolar
Body Dysmorphic Disorder
Psychosis (hearing voices)
Personality Disorder
Post-Natel Depression
Seasonally Effective Disorder
Cognitive Mood Disorder
Other
Other
Section Buttons
Diagnosis (approx year)
OCD
BPD
Schizophrenia
Hoarding
Body Dysmorphia
Bi-Polar
Psychosis
Personality Disorder
Post Natel Depression
Seasonally Effective Disorder
Cognitive Mood Disorder
Other
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Past Counselling?
Any, Past Counselling?
Yes
No
How Were They Funded?
NHS
Employment Support
Self-Paid
Other
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How Were They Funded?
Approx When?
This year
Last year
within last 5 years
6 years or more ago
Approx Number of Sessions
Any other time?
No
Yes
How Were They Funded?
NHS
Employment Support
Self-Paid
Other
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How Were They Funded?
Approx When?
This year
Last year
within last 5 years
6 years or more ago
Approx Number of Sessions
Any other times?
No
Yes
How Were They Funded?
NHS
Employment Support
Self-Paid
Other
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How Were They Funded?
Approx When?
This year
Last year
within last 5 years
6 years or more ago
Approx Number of Sessions
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Anything to add about Past Counselling?
Write in here anything you feel you would like to tell us about.
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Brief Summary of Referral
Would you like to add anything?
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If you are human, leave this field blank.
Submit