Thank you for registering your interest in our webinar.

As an NHS service we are required to take the following information to ensure our support is reaching everyone in the borough of Hillingdon.

The questionnaires below can give you and us a good indication of any symptoms you may be experiencing and, hopefully, through the session you are attending, you can learn ways to improve these.

All information is kept confidential and will not be shared with any other organisation.

If you have any further questions about this or on how to complete this form please do not hesitate to contact us on 01895 206800 or via email at hillingdontalkingtherapies.cnwl@nhs.net.

Please note: If you experience any difficulties submitting this form, please email our admin team on hillingdontalkingtherapies.cnwl@nhs.net and state which webinar you are interested in attending, and we will then get back to you.

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

Date completed Required

What is your surname? Required

What are your forenames? Required

What is your date of birth? Required

What is your post code? Required

What is your gender? Required

Male

Female

Transgender

Gender non binary

Gender Fluid / Gender Queer

I prefer not to say

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

What webinar would you like to attend? 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

Not at all (0)

Several days (1)

More than half the days (2)

Nearly every day (3)

2. Feeling down, depressed, or hopeless Required

Not at all (0)

Several days (1)

More than half the days (2)

Nearly every day (3)

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

Not at all (0)

Several days (1)

More than half the days (2)

Nearly every day (3)

4. Feeling tired or having little energy Required

Not at all (0)

Several days (1)

More than half the days (2)

Nearly every day (3)

5. Poor appetite or overeating Required

Not at all (0)

Several days (1)

More than half the days (2)

Nearly every day (3)

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

Not at all (0)

Several days (1)

More than half the days (2)

Nearly every day (3)

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

Not at all (0)

Several days (1)

More than half the days (2)

Nearly every day (3)

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

Not at all (0)

Several days (1)

More than half the days (2)

Nearly every day (3)

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

Not at all (0)

Several days (1)

More than half the days (2)

Nearly every day (3)

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

Not at all (0)

Several days (1)

More than half the days (2)

Nearly every day (3)

2.Not being able to stop or control worrying Required

Not at all (0)

Several days (1)

More than half the days (2)

Nearly every day (3)

3.Worrying too much about different things Required

Not at all (0)

Several days (1)

More than half the days (2)

Nearly every day (3)

4.Trouble relaxing Required

Not at all (0)

Several days (1)

More than half the days (2)

Nearly every day (3)

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

Not at all (0)

Several days (1)

More than half the days (2)

Nearly every day (3)

6.Becoming easily annoyed or irritable Required

Not at all (0)

Several days (1)

More than half the days (2)

Nearly every day (3)

7.Feeling afraid as if something awful might happen Required

Not at all (0)

Several days (1)

More than half the days (2)

Nearly every day (3)

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

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.

Registration form for CNWL Talking Therapies Service Hillingdon Update

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

PHQ-9

GAD-7

Phobia scales

Work and Social Adjustment