Workshop Registration Form for Hillingdon Talking Therapies

Please remember to click the submit button once you complete this form in order to send it through to the service.

Date completed Required

Which workshop would you like to attend? Required

Comfort Eating in Relation to Low Mood and Anxiety

Managing Stress

Tackling Exam Stress/Anxiety

Other

If you selected 'Other' for the workshop, please specify:

What is your surname? Required

What are your forenames? Required

What is your date of birth? Required

What is your full address, including postcode? Required

What is your gender? Required

What is your ethnicity? Required

Do you live or work in Hillingdon (please tick all that apply) Required

Live in Hillingdon

Work in Hillingdon

None of the above

Please provide us with a contact number for you Required

Please provide us with an email address for you Required

How did you hear about the workshop/webinar? (e.g. Facebook, flyer, etc) Required

PHQ-9

Over the last two weeks, how often have you been bothered by any of the following problems?

1. Little interest or pleasure in doing things Required

2. Feeling down, depressed, or hopeless Required

3. Trouble falling or staying asleep, or sleeping too much Required

4. Feeling tired or having little energy Required

5. Poor appetite or overeating Required

6. Feeling bad about yourself — or that you are a failure or have let yourself or your family down Required

7. Trouble concentrating on things, such as reading the newspaper or watching television Required

8. 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

9. Thoughts that you would be better off dead or of hurting yourself in some way Required

GAD-7

Over the last two weeks, how often have you been bothered by any of the following problems?

1.Feeling nervous, anxious or on edge Required

2.Not being able to stop or control worrying Required

3.Worrying too much about different things Required

4.Trouble relaxing Required

5.Being so restless that it is hard to sit still Required

6.Becoming easily annoyed or irritable Required

7.Feeling afraid as if something awful might happen Required

Phobia scales

Put a number next to the situations or objects below to show how much you would avoid it. 0 being you would never avoid it to 8 being you would always avoid it.

Social situations due to a fear of being embarrassed or making a fool of myself 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) 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) Required

Work and Social Adjustment

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 a scale how much your problem impairs your ability to carry out the activity. With 0 being "not at all" to 8 being "very severely."

Work Required

Home management – Cleaning, tidying, shopping, cooking, looking after home/children, paying bills etc Required

Social leisure activities - With other people, e.g. parties, pubs, outings, entertaining etc. Required

Private leisure activities – Done alone, e.g. reading, gardening, sewing, hobbies, walking etc. Required

Family and relationships– Form and maintain close relationships with others including the people that I live with Required

Additional note about GP contact: Through completing this form you are consenting to have this information stored confidentially on a secure electronic system separate from your GP’s system. If we are concerned about your safety, we may contact you or your GP regarding this.

Our Talking Therapies Services are not able to provide immediate support in an emergency. If you require immediate help please contact your GP, or your local Accident & Emergency Department, or call the Urgent Advice Line on 0800 0234 650 open 24 hours.