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Course Triage Form: Depression Recovery (Daytime)

MM slash DD slash YYYY
Voicemail consent?
Voicemail consent?

By signing up to online classes you will automatically give text consent as this is how we contact you to register for each class.

Have you ever served in the armed forces or are a dependant of someone serving?(Required)
Are you pregnant or have caring responsibility for a child under 12 months?(Required)

Below are a few short questionnaires to help us understand your current symptoms. You will be asked to complete these for every session with our service, to help us monitor your progress.

PHQ-9

Over the last 2 weeks, how often have you felt little interest or pleasure in doing things(Required)
Over the last 2 weeks, how often have you felt down, depressed, or hopeless(Required)
Over the last 2 weeks, how often have you had trouble falling or staying asleep, or sleeping too much(Required)
Over the last 2 weeks, how often have you felt tired or had little energy(Required)
Over the last 2 weeks, how often have you had a poor appetite or overeating(Required)
Over the last 2 weeks, how often have you felt bad about yourself - or that you are a failure or have let yourself or your family down(Required)
Over the last 2 weeks, how often have you had trouble concentrating on things, such as reading the newspaper or watching television(Required)
Over the last 2 weeks, how often have you had been bothered by 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(Required)
Over the last 2 weeks, how often have you had thoughts that you would be better off dead or of hurting yourself in some way(Required)

GAD-7

Over the last 2 weeks, how often have you felt nervous, anxious or on edge(Required)
Over the last 2 weeks, how often have you not been able to stop or control worrying(Required)
Over the last 2 weeks, how often have you not been able to stop worrying too much about different things(Required)
Over the last 2 weeks, how often have you had trouble relaxing(Required)
Over the last 2 weeks, how often have you been so restless that it is hard to sit still(Required)
Over the last 2 weeks, how often have you become easily annoyed or irritable(Required)
Over the last 2 weeks, how often have you felt afraid as if something awful might happen(Required)
Choose a number from the scale above to show how much you would avoid each of the situations or objects listed below.(Required)
Social situations due to a fear of being embarrassed or making a fool of myself
Choose a number from the scale above to show how much you would avoid each of the situations or objects listed below.(Required)
Certain situations because of a fear of particular objects or activities (such as animals, heights, seeing blood, being in confined spaces, driving or flying)
Choose a number from the scale above to show how much you would avoid each of the situations or objects listed below.(Required)
Certain situations because of a fear of having a panic attack or other distressing symptoms (such as loss of bladder control, vomiting or dizziness)
People's problems sometimes affect their ability to do certain day-to-day tasks in their lives. To rate your problems look at each section and determine on the scale above how much your problem impairs your ability to carry out the activity(Required)
WORK - If you are retired or choose not to have a job for reasons unrelated to your problem, please tick N/A (not applicable)
People's problems sometimes affect their ability to do certain day-to-day tasks in their lives. To rate your problems look at each section and determine on the scale above how much your problem impairs your ability to carry out the activity(Required)
HOME MANAGEMENT - Cleaning, tidying, shopping, cooking, looking after home/children, paying bills etc.
People's problems sometimes affect their ability to do certain day-to-day tasks in their lives. To rate your problems look at each section and determine on the scale above how much your problem impairs your ability to carry out the activity(Required)
SOCIAL LEISURE ACTIVITIES - With other people, e.g. parties, pubs, outings, entertaining etc.
People's problems sometimes affect their ability to do certain day-to-day tasks in their lives. To rate your problems look at each section and determine on the scale above how much your problem impairs your ability to carry out the activity(Required)
PRIVATE LEISURE ACTIVITIES - Done alone, e.g. reading, gardening, sewing, hobbies, walking etc.
People's problems sometimes affect their ability to do certain day-to-day tasks in their lives. To rate your problems look at each section and determine on the scale above how much your problem impairs your ability to carry out the activity(Required)
FAMILY AND RELATIONSHIPS - Form and maintain close relationships with others including the people that I live with

Medications

Employment status questions

Are you currently receiving Statutory Sick Pay?(Required)
Are you suitable for or feel you would benefit from receiving employment support?(Required)

Employment advisors in IAPT pilot questions

What is your current employment status?(Required)
Are you currently in receipt of benefits?(Required)
If yes, please tick the benefits you currently receive(Required)
Consent(Required)