Intake Form What is your gender? * How would you describe your sexual orientation? * Do you consider yourself to have a major illness or disability? * Yes No If yes please indicate the nature of your disability: Have you received any other professional support or help? * Yes No Are you currently taking medication for mental health? * Yes No Do you have any children under the age of 18? * Yes No How would you describe your relationship status? * Please answer the following questions in relation to the last 7 days choosing from the options displayed: * I felt alone and isolated Not at all Only occasionally Sometimes Often Always 2. * I have felt I have someone to turn to for support when needed Not at all Only occasionally Sometimes Often Always 3. * I have been physically violent to others Not at all Occasionally Sometimes Often Always 4. * I have felt able to cope when things go wrong Not at all Occasionally Sometimes Often Always 5. * I have thought of hurting myself Not at all Occasionally Sometimes Often Always 6. * I have been happy with the things I have done Not at all Occasionally Sometimes Often Always 7. * I have been disturbed by unwanted thoughts and feelings Not at all Occasionally Sometimes Often Always 8. * I made plans to end my life Not at all Occasionally Sometimes Often Always 9. * I have felt unhappy Not at all Occasionally Sometimes Often Always 10. * I have felt optimistic about the future Not at all Occasionally Sometimes Often Always 11. * I have felt totally lacking in energy and enthusiasm Not at all Occasionally Sometimes Often Always 12. * I have thought I would be better I were dead Not at all Occasionally Sometimes Often Always 13. * I have hurt myself physically or taken dangerous risks with my own health Not at all Occasionally Sometimes Often Always 14. * I have had difficulty getting to sleep or staying asleep Not at all Occasionally Sometimes Often Always Please answer the following questions in relation to the anytime in the past choosing from the options displayed: * I felt alone and isolated Not at all Occasionally Sometimes Often Always 2b. I have felt I have someone to turn to for support when needed Not at all Occasionally Sometimes Often Always 3b. * I have been physically violent to others Not at all Occasionally Sometimes Often Always 4b. * I have felt able to cope when things go wrong Not at all Occasionally Sometimes Often Always 5b. * I have thought of hurting myself Not at all Occasionally Sometimes Often Always 6b. * I have been happy with the things I have done Not at all Occasionally Sometimes Often Always 7b. I have been disturbed by unwanted thoughts and feelings Not at all Occasionally Someties Often Always 8b. * I made plans to end my life Not at all Occasionally Sometimes Often Always 9b. * I have felt unhappy Not at all Occasionally Sometimes Often Always 10b. I have felt optimistic about the future Not at all Occasionally Sometimes Often Always 11b. * I have felt totally lacking in energy and enthusiasm Not at all Occasionally Sometimes Often Always 12b. * I have thought I would be better I were dead Not at all Occasionally Sometimes Often Always 13b. * I have hurt myself physically or taken dangerous risks with my own health Not at all Occasionally Sometimes Often Always 14b. * I have had difficulty getting to sleep or staying asleep Not at all Occasionally Sometimes Often Always Are you currently receiving professional help from other services (for example Social workers, therapists, psychiatrist and so on)? * Yes No What is your occupation? * How would you describe your employment status? * Thank you!