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 Date of

Number Birth
Address (including
Postcode)

Home Tel No Mobile Email

No
Ethnicity (please Ethnic origin (please highlight):
circle/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 Other Sight Speech
Personal Self Care, Manual No perceived
Not Stated
Confidence Dexterity Disability
Perception of Physical
If Other please give details:
Danger
Any issues with
Drug Misuse; Alcohol Misuse; Drug and Alcohol Is client in receipt of
drugs or alcohol?
Misuse; Not stated; No Drug or Alcohol Issue SSP?
(select all that apply)
Current Employment Full time (30+ hrs); Part time; Unemployed; Retired; Self-employed; Full time student
Status (please Full time homemaker/carer ; Sick leave (still employed) ; Unable to work (due to
circle/highlight) illness/mental health); Not specified
Currently receiving If yes please
any benefits? state benefits
Name of GP

GP Surgery Address Contact

Number

F 51 V4 Page 1 of 3
 more
PHQ- Over the last 2 weeks (or other agreed time
period) how often have you been bothered by
not several than
nearly
every
9 at all days half the
any of the following problems? day
days
1 Little interest or pleasure in doing things 0 1 2 3
.
2 Feeling down, depressed, or hopeless 0 1 2 3
.
3 Trouble falling or staying asleep, or sleeping too much 0 1 2 3
.
4 Feeling tired or having little energy 0 1 2 3
.
5 Poor appetite or overeating 0 1 2 3
.
6 Feeling bad about yourself or that you are a
failure or have let yourself or your family down
0 1 2 3
.
7 Trouble concentrating on things, such as
reading the newspaper or watching television
0 1 2 3
.
Moving or speaking so slowly that other people could
8 have noticed? Or the opposite being so fidgety or 0 1 2 3
. restless that you have been moving around a lot more
than usual
9 Thoughts that you would be better off
dead or of hurting yourself in some way
0 1 2 3
.
PHQ-9 total score =

F 51 V4 Page 2 of 3
 Over the last 2 weeks (or other agreed time more nearly
GAD- period) how often have you been bothered by
not several than every
7 any of the following problems?
at all days half the day
days
1 Feeling nervous, anxious or on edge 0 1 2 3
2. Not being able to stop or control worrying 0 1 2 3
3. Worrying too much about different things 0 1 2 3
4. Trouble relaxing 0 1 2 3
5. Being so restless that it is hard to sit still 0 1 2 3
6. Becoming easily annoyed or irritable 0 1 2 3
7. Feeling afraid as if something awful might happen 0 1 2 3
.
GAD-7 total score =

F 51 V4 Page 3 of 3