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Sight Loss Questionnaire
Complex Care Counselling
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Sight Loss Questionnaire
Sight Loss Questionnaire
Questionnaire
Why?
Sight Loss is a complex condition, it has many variations, and you could have additional sensory or physical symptoms. This Questionnaire asks about your Sight Loss and any coexisting problems, the aim is to give your counsellor a full understanding before you start your first session.
Confidential
All information you enter into this online form is fully confidential. The information will be shared only with your specialist counsellor.
Self Paid Counselling
If you are not asking for a NHS application for free funding, you do not need to complete this questionnaire, its your choice. If this is the case just close this webpage.
For NHS Funded Counselling
If you would like DisabilityPlus to make a free funding application, we have to prove why you are best suited to a counsellor who has sight loss. As a disabilities company we know its just another hoop we have to jump through just like you do every day.
NHS Application
If DisabilityPlus are going to make an NHS application for the purpose of free funding. The information you insert will be used to make a free funding application for you.
Complexity
The form should not take more than 5 minutes to complete. We have made it as user-friendly as possible; however, if you feel you cannot complete it or would prefer a telephone call, select from the buttons after your contact details ” No, I would like a telephone call for help to complete it”.
Your Contact Details (person who wants counselling)
Your Name?
*
PostCode?
*
Funding
Type
Self-paid (immediate start)
Self-paid to start and a NHS application
NHS application only
Other
Other
Self-paying
On completion of this form you will start your sessions within two weeks. The pricing is: £50 introduction Session £180 for 3 sessions or £70 pay-as-you-go. Please talk to us if you are in financial difficulties.
NHS Funding
NHS Funding cannot be guaranteed, each NHS region has different rules. On selecting NHS application and completing this form you will receive a assessment session by our blind counsellor. We then send a application to your GP based on your unique circumstances, there is then generally a twelve week wait for a decision by the NHS to approve your funding or decline funding. You can self-pay to start counselling immediately and in the background we can make the application for you.
Continue?
Continue to the form?
No, I would like a telephone call for help to complete it.
I want to continue to the form
Who is completing this form?
Please tell us who is completing the form?
Myself
Partner
Carer
Mother/Father
Family memeber
Social services
Other
Other
If one or more people are completing this form multi-select from the answers above.
If you are human, leave this field blank.
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