Date of referral:

Patient ID:
Service Request ID:

Please come to see us after completing and printing this form on Monday 20 th June, from 12 pm to 3 pm.
Or call us if you have any questions at 0151 649 1674 (Michelle) or at 07966899077 (Federica). The
information you will provide will be kept strictly confidential (protected under NHS confidentiality policy) and
will not be shared with your employer.
Client Name

NHS
Number

Date of
Birth

Address (including
Postcode)
Home Tel No
Ethnicity (please
circle/highlight)

Mobile
No

Email

Ethnic origin (please highlight):

White;
British / Irish / Other / Roma/Gypsy/Traveller - Black or Blac
British; Caribbean African - Other Mixed;
White & Black Caribbean /
White & Black African / White & Asian Other Chinese / Other
Unknown/Asian or Asian British; Indian / Pakistani / Bangladeshi / Other

Religion (if stated)

Sexual Orientation (if stated)

Pre Peri-natal/Baby
under 1
British Armed
Currently Serving; Ex Services; No; Not Stated; Unknown
Gender
Forces
Disability (select all that apply)
Long Term
Reading or writing
Memory
Hearing
Condition
Mobility
Personal Self Care,
Confidence
Perception of Physical
Danger
Any issues with
drugs or alcohol?
(select all that apply)
Current Employment
Status (please
circle/highlight)
Currently receiving
any benefits?
Name of GP
GP Surgery Address

F 51 V4

Other

Sight

Speech

Not Stated

Manual
Dexterity

No perceived
Disability

If Other please give details:

Drug Misuse; Alcohol Misuse; Drug and Alcohol
Misuse; Not stated; No Drug or Alcohol Issue

Is client in receipt of
SSP?

Full time (30+ hrs); Part time; Unemployed;

Retired; Self-employed; Full time student
Full time homemaker/carer ; Sick leave (still employed) ; Unable to work (due to
illness/mental health); Not specified
If yes please
state benefits

Contact
Number

Page 1 of 3

more
than
half the
days

nearly
every
day

Feeling tired or having little energy

Poor appetite or overeating

Feeling bad about yourself or that you are a

failure or have let yourself or your family down

Trouble concentrating on things, such as

reading the newspaper or watching television
Moving or speaking so slowly that other people could
have noticed? Or the opposite being so fidgety or
restless that you have been moving around a lot more
than usual
Thoughts that you would be better off
dead or of hurting yourself in some way

PHQ9
1
.
2
.
3
.
4
.
5
.
6
.
7
.
8
.
9
.

Over the last 2 weeks (or other agreed time

period) how often have you been bothered by
any of the following problems?

not
at all

several
days

Little interest or pleasure in doing things

Feeling down, depressed, or hopeless

Trouble falling or staying asleep, or sleeping too much

PHQ-9 total score =

F 51 V4

Page 2 of 3

more
than
half the
days

nearly
every
day

Trouble relaxing

Being so restless that it is hard to sit still

Becoming easily annoyed or irritable

Feeling afraid as if something awful might happen

GAD7
1
2.
3.
4.
5.
6.
7.
.

Over the last 2 weeks (or other agreed time

period) how often have you been bothered by
any of the following problems?

not
at all

several
days

Feeling nervous, anxious or on edge

Not being able to stop or control worrying

Worrying too much about different things

GAD-7 total score =

F 51 V4

Page 3 of 3