Self-referral | PCIAA questionnairePlease complete this form prior to your counselling assessment session with My Therapist Pamela Title * Other Mr Mrs Miss Ms Mx Dr Rev Prof Name * First Name Last Name Date of birth * MM DD YYYY Gender * Male Female Not specified Not disclosed Marital status * Prefer not to say. Not disclosed Single Married Divorced Widowed Separated Co-habiting Long term Civil partnership Address Address 1 Address 2 City State/Province Zip/Postal Code Country Permission to send written communication via post? * Yes No Phone number Phone type Home Work Other Permission to leave voicemail? Yes No Mobile Number Permission to leave voicemail Yes No Permission to leave SMS text Yes No Email Permission to send email * Yes No Next of Kin (in an emergency): Next of Kin Contact Number (###) ### #### GP Name GP Surgery Name * GP Surgery Address GP Contact number Permission to share information with GP * Yes No Or Confirm my consent if / when required Language * Able to communicate in English? * Yes No Interpreter required? Yes No Ethnicity * Not known Not stated White British White Irish White - any other White background Mixed - White and Black Carribean Mixed - White and Black African Mixed - White and Asian Mixed - Any other mixed background Asian or Asian British - Indian Asian or Asian British - Pakistani Asian or Asian British - Bangladeshi Asian or Asian British - Any other Asian Background Black or Black British - Carribean Black or Black British - African Black or Black British - Any other Black background Chinese Religious or Belief affiliation * Prefer not to say. Not stated Buddhist Christian Hindu Jain Jewish Muslim No religious group or secular Pagan Parsi / Zoroastrian Unknown Sikh Ex-British Armed Forces No Yes - currently serving (including reservists) Yes - Ex-Services Dependant of a serving member Not stated Unknown Sexuality Prefer not to say. Hetrosexual Lesbian Gay Bisexual Other Not known Not stated Do you identify as the same gender you were assigned at birth? * Yes No Prefer not to answer Mobility issues * Yes No Long-term medical conditions * Other Asthma Cancer Chronic pain Dementia Diabetes Epilepsy Heart failure Medically unexplained symptoms None Does this condition have an impact on your mental health? Yes No Disability * None Behaviour or emotional Hearing Manual dexterity Memory, or ability to concentrate or understand (learning disability) Mobility and gross motor Perception of physical danger Personal, self-care or continence Progessive conditions and physcial health (e.g. HIV, Cancer, MS) Sight Speech Other Do not wish to say Are you currently in receipt of any other form of therapy/seeing any other mental health professional e.g. CPN, psychologist, psychiatrist or service (AMH/CAMHS/other)? * Yes No If yes, please provide details: Have you had any formal diagnosis from a GP, psychiatrist or other mental health professional? * Yes No If yes, please provide details: Are you currently taking any medication, which has been prescribed by a doctor? * Yes No If yes, please provide details of medication prescribed: Brief details of why you wish to access My Therapist Pamela's services and counselling? * Your availability: Please describe your availability and when you would prefer to have counselling sessions with My Therapist Pamela (day/evenings or weekends): Confirmation - You provide consent for your information to be processed in concordance with data protection legislation. * My Therapist Pamela is General Data Protection Regulation (GDPR) trained, and adheres to the requirements of data protection legislation, processing information lawfully and securely. Your consent: Yes, I understand and agree to My Therapist Pamela processing my information for the counselling services provided, and consent to proceed, and to be contacted as confirmed in this form. Thank you for completing this form.My Therapist Pamela will be in contact within the next 24 to 74 hours (three working days). If you have any queries in the meantime, please use the contact form.
