Referral Assessment Question Title * 1. Name Question Title * 2. Referral Source Self Referral GP Care Merseyside Other (please specify) Question Title * 3. Gender Male Female Prefer not to say Other (please specify) Question Title * 4. age 18-24 25-34 35-44 45-54 55-64 65+ Question Title * 5. Area of GP Liverpool Knowsley Sefton Wirral Other (please specify) Question Title * 6. Referral Reason (click more than one if appropriate) Low Mood Anxiety Stress Financial Support Education Isolation Addiction For Carer Support Other (please specify) Question Title * 7. Please rate your current need in each area (1 need support / 10 - do not need support) 1 2 3 4 5 6 7 8 9 10 Stress levels Stress levels 1 Stress levels 2 Stress levels 3 Stress levels 4 Stress levels 5 Stress levels 6 Stress levels 7 Stress levels 8 Stress levels 9 Stress levels 10 Anxiety Anxiety 1 Anxiety 2 Anxiety 3 Anxiety 4 Anxiety 5 Anxiety 6 Anxiety 7 Anxiety 8 Anxiety 9 Anxiety 10 Low mood Low mood 1 Low mood 2 Low mood 3 Low mood 4 Low mood 5 Low mood 6 Low mood 7 Low mood 8 Low mood 9 Low mood 10 Finances/housing situation Finances/housing situation 1 Finances/housing situation 2 Finances/housing situation 3 Finances/housing situation 4 Finances/housing situation 5 Finances/housing situation 6 Finances/housing situation 7 Finances/housing situation 8 Finances/housing situation 9 Finances/housing situation 10 Physical well-being Physical well-being 1 Physical well-being 2 Physical well-being 3 Physical well-being 4 Physical well-being 5 Physical well-being 6 Physical well-being 7 Physical well-being 8 Physical well-being 9 Physical well-being 10 Mental Health education Mental Health education 1 Mental Health education 2 Mental Health education 3 Mental Health education 4 Mental Health education 5 Mental Health education 6 Mental Health education 7 Mental Health education 8 Mental Health education 9 Mental Health education 10 Relationships with others Relationships with others 1 Relationships with others 2 Relationships with others 3 Relationships with others 4 Relationships with others 5 Relationships with others 6 Relationships with others 7 Relationships with others 8 Relationships with others 9 Relationships with others 10 Self esteem Self esteem 1 Self esteem 2 Self esteem 3 Self esteem 4 Self esteem 5 Self esteem 6 Self esteem 7 Self esteem 8 Self esteem 9 Self esteem 10 Addiction Addiction 1 Addiction 2 Addiction 3 Addiction 4 Addiction 5 Addiction 6 Addiction 7 Addiction 8 Addiction 9 Addiction 10 Other (please specify) and give rating 1-10 Question Title * 8. What form of support would you prefer (please tick all that apply) Individual 1-1 sessions Group Sessions Online Zoom Sessions Support group Other (please specify) Question Title * 9. What workshops would you be interested in attending Mindset & goal setting Mental Health Awareness Stress & Anxiety management Mindfulness & Relaxation Low self esteem & Building Resilience Financial Well-being Addiction Loss and Relationship breakdown Physical well-being & Positive habits Question Title * 10. Please leave your email address below and one of the Evolving Mindset Team will contact you as soon as possible. Email Address Question Title * 11. I understand that Evolving Mindset are not a Clinical Mental Health Service - we still advise to seek advice from your GP or professional team. We are a community interest network that can provide bespoke education and support for people experiencing mild to moderate mental health concerns and/or carers. We are also able to signpost you to other support networks which may be best suited to support your needs. Agree Question Title * 12. I understand that It is a basic principle of Evolving Mindset that we offer confidentiality to participants. I agree to maintain confidentiality of others when accessing support from Evolving Mindset Agree Done
