Cricket Referral

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* 1. Full Name:

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* 2. Date of Birth:

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* 3. Mobile Number:

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* 4. Email Address:

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* 5. Please provide the name and address of your GP (if known):

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* 6. Please check the box below if you are happy for us to contact your GP

I am happy for you to contact my GP

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* 7. Reason for contacting the service:

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* 8. Over the last 2 weeks, how often have you been bothered by any of the following problems?

	Not at all	Several days	More than half the days	Nearly every day
Little interest or pleasure in doing things	Little interest or pleasure in doing things Not at all	Little interest or pleasure in doing things Several days	Little interest or pleasure in doing things More than half the days	Little interest or pleasure in doing things Nearly every day
Feeling down, depressed or hopeless	Feeling down, depressed or hopeless Not at all	Feeling down, depressed or hopeless Several days	Feeling down, depressed or hopeless More than half the days	Feeling down, depressed or hopeless Nearly every day
Trouble falling or staying asleep or sleeping too much	Trouble falling or staying asleep or sleeping too much Not at all	Trouble falling or staying asleep or sleeping too much Several days	Trouble falling or staying asleep or sleeping too much More than half the days	Trouble falling or staying asleep or sleeping too much Nearly every day
Feeling tired or having little energy	Feeling tired or having little energy Not at all	Feeling tired or having little energy Several days	Feeling tired or having little energy More than half the days	Feeling tired or having little energy Nearly every day
Poor appetite or over eating	Poor appetite or over eating Not at all	Poor appetite or over eating Several days	Poor appetite or over eating More than half the days	Poor appetite or over eating Nearly every day
Feeling bad about yourself or that you are a failure or have let yourself or your family down	Feeling bad about yourself or that you are a failure or have let yourself or your family down Not at all	Feeling bad about yourself or that you are a failure or have let yourself or your family down Several days	Feeling bad about yourself or that you are a failure or have let yourself or your family down More than half the days	Feeling bad about yourself or that you are a failure or have let yourself or your family down Nearly every day
Trouble concentrating on things such as reading the newspaper or watching television	Trouble concentrating on things such as reading the newspaper or watching television Not at all	Trouble concentrating on things such as reading the newspaper or watching television Several days	Trouble concentrating on things such as reading the newspaper or watching television More than half the days	Trouble concentrating on things such as reading the newspaper or watching television Nearly every day
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	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 Not at all	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 Several days	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 More than half the days	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 Nearly every day
Thoughts that you would be better off dead or hurting yourself in some way	Thoughts that you would be better off dead or hurting yourself in some way Not at all	Thoughts that you would be better off dead or hurting yourself in some way Several days	Thoughts that you would be better off dead or hurting yourself in some way More than half the days	Thoughts that you would be better off dead or hurting yourself in some way Nearly every day

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* 9. Over the last 2 weeks, how often have you been bothered by the following problems?

	Not at all	Several days	More than half the days	Nearly every day
Feeling nervous, anxious or on edge	Feeling nervous, anxious or on edge Not at all	Feeling nervous, anxious or on edge Several days	Feeling nervous, anxious or on edge More than half the days	Feeling nervous, anxious or on edge Nearly every day
Not being able to stop or control worrying	Not being able to stop or control worrying Not at all	Not being able to stop or control worrying Several days	Not being able to stop or control worrying More than half the days	Not being able to stop or control worrying Nearly every day
Worrying too much about different things	Worrying too much about different things Not at all	Worrying too much about different things Several days	Worrying too much about different things More than half the days	Worrying too much about different things Nearly every day
Trouble relaxing	Trouble relaxing Not at all	Trouble relaxing Several days	Trouble relaxing More than half the days	Trouble relaxing Nearly every day
Being so restless that it is hard to sit still	Being so restless that it is hard to sit still Not at all	Being so restless that it is hard to sit still Several days	Being so restless that it is hard to sit still More than half the days	Being so restless that it is hard to sit still Nearly every day
Becoming easily annoyed or irritable	Becoming easily annoyed or irritable Not at all	Becoming easily annoyed or irritable Several days	Becoming easily annoyed or irritable More than half the days	Becoming easily annoyed or irritable Nearly every day
Feeling afraid as if something awful might happen	Feeling afraid as if something awful might happen Not at all	Feeling afraid as if something awful might happen Several days	Feeling afraid as if something awful might happen More than half the days	Feeling afraid as if something awful might happen Nearly every day

Please now submit your form below. We will be in touch as soon as possible. If urgent, please contact NHS 24 on 111.