Please indicate which Listening Space you require Please indicate which Listening Space you require Via video link 9am - 7pm (weekdays)

Only complete this form if you are (please tick) ... Only complete this form if you are (please tick) ... Over 18 living within a 20km radius of Ripon Over 18 living outside a 20km radius of Ripon or over 18 and prepared to pay the full cost of therapy

Name

Address

Email Address

Contact Tel No (Is it safe to call and leave a message on this number? )

Is this referral for yourself? Otherwise due to data protection you cannot refer someone else. Is this referral for yourself? Otherwise due to data protection you cannot refer someone else. Yes No

Would you like to be considered for twenty subsidised counselling sessions with a mature university student counsellor? Would you like to be considered for twenty subsidised counselling sessions with a mature university student counsellor? Yes No

What is your age & location (or if on behalf of someone else please give the person's age and location)

Have you historically experienced any of the following Adverse Childhood Experiences (tick all that apply): Have you historically experienced any of the following Adverse Childhood Experiences (tick all that apply): Physical Abuse Sexual Abuse Emotional Abuse Neglect Incarcerated Parents Parental Drug/Alcohol Use

Are you currently experiencing any of the following (tick all that apply): Are you currently experiencing any of the following (tick all that apply): Physical Abuse Sexual Abuse Emotional Abuse Drug/Alcohol Use Eating Disorders Self Harm

Have you experienced any medical or birth trauma?

Are you using: Are you using: Recreational Drugs Class A Drugs Recreational Alcohol None of the Above

Have you ever been sectioned? Have you ever been sectioned? Yes No

Have you ever attempted suicide? Have you ever attempted suicide? Yes - within the last 12 months Yes - within the last 5 years Yes - within the last 10 years No

Have you ever been convicted of a criminal offence? Have you ever been convicted of a criminal offence? Yes No

Please tell us if a GP has been involved about the symptoms? Please tell us if a GP has been involved about the symptoms? Yes No

If you answered 'Yes' to the above - please give your GP's details

Trauma is defined as anything that has had a long-lasting negative effect, this can be psychological, physical or emotional; would you consider this to be the case? Trauma is defined as anything that has had a long-lasting negative effect, this can be psychological, physical or emotional; would you consider this to be the case? Yes No

Please tell us what other approaches that have been tried for support (if any)

Would you consider this problem as a safeguarding issue? (high risk of immediate harm) Would you consider this problem as a safeguarding issue? (high risk of immediate harm) Yes No

Please give a brief history of the issue (100 words)

In relation to your sleep patterns, please choose an answer below In relation to your sleep patterns, please choose an answer below I am sleeping well I have some difficulty sleeping I have frequently disturbed sleep I get very little or no sleep

In relation to your daily activities, please choose an answer below In relation to your daily activities, please choose an answer below I manage day-to-day activities well I have some difficulties but coping I am struggling with daily tasks I am unable to manage daily activities

In relation to your work or education, please choose an answer below In relation to your work or education, please choose an answer below I am attending as usual I am attending but finding it difficult I am frequently missing days I am not currently able to attend

In relation to your emotional wellbeing, please choose an answer below In relation to your emotional wellbeing, please choose an answer below I am generally feeling okay I am feeling low or anxious at times I am often feeling overwhelmed I am constantly overwhelmed

In relation to your support network, please choose an answer below In relation to your support network, please choose an answer below I feel well supported I have some support I have limited support I feel alone

In relation to your physical health and energy, please choose an answer below In relation to your physical health and energy, please choose an answer below I have good energy and health I have some fatigue or health concerns I have low energy most of the time I have very low energy / struggling physically

In relation to coping with things, please choose an answer below In relation to coping with things, please choose an answer below I feel able to cope I’m just about coping I’m struggling to cope I don’t feel I’m coping

In relation to safety, please choose an answer below In relation to safety, please choose an answer below I feel safe I sometimes feel unsafe or distressed I often feel unsafe or distressed I would like support with feeling safe

In relation to your ability to settle after distress, please choose an answer below In relation to your ability to settle after distress, please choose an answer below I can calm myself fairly quickly It takes me a little while to settle It can take a long time to feel calm again I struggle to calm myself without support

What are you hoping for from support? What are you hoping for from support? Someone to talk to Help with anxiety or low mood Support during a difficult time Not sure, but I need support

Previous support Previous support No previous support Had some support in the past Currently receiving support elsewhere

Use of Personal Information (Please tick to confirm) Use of Personal Information (Please tick to confirm) I understand that once submitted my information will be entered into The Wellness Gateway's CRM system which is managed by Kulahub.com and certain staff members will have access to it.

How did you hear about us?

Are you in receipt of benefits? Unless you have opted for free sessions with a student, please be aware that sessions are subsidised at £45 each. Evidence of some benefits will discount this cost. Are you in receipt of benefits? Unless you have opted for free sessions with a student, please be aware that sessions are subsidised at £45 each. Evidence of some benefits will discount this cost. Yes No

If yes, which benefits?

Are you currently being supported by secondary care services such as Community Mental Health Teams? If so, please expand on your situation.

If we do offer therapy or counselling it is not ethical for us to support anyone receiving therapy, support or counselling elsewhere (NHS, IAPT, CMHT or private therapy) If we do offer therapy or counselling it is not ethical for us to support anyone receiving therapy, support or counselling elsewhere (NHS, IAPT, CMHT or private therapy) I Understand

How did you hear about us? How did you hear about us?Via a friend or relativeVia a professional bodyVia Econ EngineeringVia Greenwoods SolicitirsSocial MediaGoogle / Internet SearchOther

Would you like to opt in to our database to receive regular news from us? Would you like to opt in to our database to receive regular news from us? Yes No