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Psychological Services – Additional Health Information

This form is to enable our practitioners to gain a better understanding of your needs and to help you to identify what support might best help.

The form will take about 30 minutes to complete and will ask questions about yourself, any support you may have had in the past, and what support you are in receipt of now. It is important that we understand your current circumstances and your personal goals.

The Fire Fighters Charity operates a non-judgmental approach. It is therefore important that you answer these questions honestly and fully so we can work with you to identify the most appropriate support to meet your needs. The information provided on this form will be treated as confidential, so it is important that you provide as much information as possible that is true and accurate to the best of your knowledge

The Fire Fighters Charity offers a range of different support pathways tailored to meet your individual need. If we cannot meet your needs through the Charity’s services, we will work with you to identify what support is available to you through other organisations.

Please ensure that you have completed the form in full and take time to read the next steps section. Please note that completing this form does not necessarily mean that you will be offered support. The information on this form helps us assess whether our psychological services can meet your needs, in some situations other support options may be more appropriate.

If you have any questions regarding this form, please contact our team on 0800 389 8820

Please provide your details below (or the name of the person in need of support if you are completing the form on someone else’s behalf):

Personal Details

First Name

Last Name

Birthdate

Preferred Contact Method

Like to be known as (name)

Mailing Street

Mailing City (Please use capitals)

Mailing County

Mailing Postcode (Please use capitals and in format xxxx xxx)

Mobile Phone

Enter in the XXXXX XXXXXX format

Home Phone

Enter in the XXXXX XXXXXX format

Consent to leave a voicemail

GP Details

GP Name

GP Address

GP Telephone

Confirmation to approach GP

Understanding your needs

It is important that we have a good understanding of how you are feeling now, what you are struggling with, and what strategies you are using to manage your psychological health. It is also essential that we understand your medical history, what support you have received in the past and who is supporting you now.

Why you have approached the Charity for Support?

Thinking about your reason for accessing support from The Fire Fighters Charity, what are your aims/goals

Please use this section to provide details of your previous medical history. Please include anything you think is relevant and details of how this impacts your psychological health.

Please List below all prescribed medication and over the counter medications that you are currently taking. Please provide details why you are taking this medication, the dosage and frequency.

	Medication:	Prescribed for:	Date initially prescribed:	Dosage/Frequency:

Are you currently seeing anyone regarding psychological issues? --Please select from the drop-down field

Have you previously been under the care of anyone regarding psychological issues? --Please select from the drop-down field

Please provide further details below including the type of practitioner and their name and contact details:

Psychological Practitioner Name

Profession

Address (including postcode)

Contact Telephone 1

Contact Telephone 2

May we approach this person for any additional information we may need?

YesNo

Please read each statement below and select the response which indicates how often you have felt that way over the last month. Please note – the information in brackets is for office use only and should not affect your response

Each question must be answered.

	Not at all	Only occasionally	Sometimes	Often	Most or all of the time
1. I have felt tense, anxious or nervous
2. I have felt totally lacking in energy and enthusiasm
3. I have been physically violent to others
4. I have been troubled by aches and pains or other physical problems
5. I have thought of hurting myself
6. Tension and anxiety have prevented me doing important things
7. I have been disturbed by unwanted thoughts and feelings
8. I have felt panic or terror
9. I made plans to end life
10. I have had difficulty getting to sleep or staying asleep
11. My problems have been impossible to put to one side
12. I have threatened or intimidated another person
13. I have felt despairing or hopeless
14. I have thought it would be better if I were dead
15. I have felt unhappy
16. Unwanted images or memories have been distressing me
17. I have thought I am to blame for my problems and difficulties
18. I have hurt myself physically or taken dangerous risks with my health

Have you ever used alcohol, drugs, prescribed or non-prescribed medication as a coping strategy?

YesNo

If yes, please give further information (including dates)

Please complete the following Alcohol

Screening form.

	1-2	3-4	5-6	7-9	10+
How many units of alcohol do you drink on a typical day when you are drinking? 1 unit is typically half a pint of regular beer, lager or cider; 1 small glass of low ABV wine (9%); 1 single measure of spirits (25ml)

	Never	Less than monthly	Monthly	Weekly	Daily or almost daily
How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year?

Your Total Score

Total

If you have scored 5 or more please complete the following 7 questions. If you have scored less than 5 please go to the next page.

	Never	Less than a monthly	Monthly	Weekly	Daily or almost daily
How often during the last year have you found that you were not able to stop drinking once you had started?
How often during the last year have you failed to do what was normally expected from you because of your drinking?
How often during the last year have you needed an alcoholic drink in the morning to get yourself going after a heavy drinking session?
How often during the last year have you had a feeling of guilt or remorse after drinking?
How often during the last year have you been unable to remember what happened the night before because you had been drinking?

	No	Yes, but not in the last year	Yes, during the last year
Have you or somebody else been injured as a result of your drinking?
Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested that you cut down?

Your Total Scores

Total

Please use this section to provide any additional detail. It would be helpful to understand the support networks you currently have in place and what strategies you are currently adopting to improve your psychological health.

Thank you for completing this form. The information provided on this form will help our Psychological Services Team understand your needs and identify what support will help you to move forward.

Please read the following statements.

Please note that by submitting this form you confirm that you have read the following statements and understand how your information will be stored and processed and the Charity’s policy on confidentiality.

Confidentiality Policy

The information that our beneficiaries entrust to the Charity will be held in confidence. This confidence will be maintained and applied to any and all records, in accordance with the Data Protection Act, except in the following instances:

· When a court of law requires information.

· When there is a risk of harm to self or others. Whenever possible, this will be discussed with you before action is taken.

· When a child is at risk of neglect, physical, emotional, psychological or sexual abuse. Whenever possible, this will be discussed with you before action is taken.

· At times, in supervision with another colleague, to promote the highest standard of practice, in which case the client’s identity will be protected.

· When multidisciplinary team members involved in your care need to be consulted and/or updated on your progress. This is on a need to know basis.

· When a referring GP or agency requires feedback on attendance. We would not confer with your doctor or an outside agency without your knowledge and permission except in situations associated with risk.

Record Keeping and Data Protection

The Fire Fighters Charity stores beneficiary information securely in our electronic case management system. The Fire Fighters Charity also undergoes auditing to ensure documentation etc. is kept at an appropriate standard.

The Fire Fighters Charity processes personal data in accordance with its Data Protection Policy. For full details of how the Charity processes your data, please see our Privacy Policy www.firefightercharity.org.uk/privacy

Date

Data Protection Agreement

Declaration Agreement

If you have completed this form on behalf of someone else, please provide your details below, including your name, relationship to the person in need of support, your telephone number and email address.

Next Steps

You will be offered an initial assessment with a member of the Psychological Services Team to discuss your psychological needs in more detail. If we feel we need more information or feel that another service may be best suited to meet your needs we will contact you to discuss this further.

Please note. All beneficiaries receiving telephone or online counselling from The Fire Fighters Charity will be required to sign an agreement, this is our contract with you. This agreement outlines our policy on confidentiality, timings for sessions, boundaries, cancellations, missed appointments and complaints. If relevant you will be sent this agreement for completion following your initial assessment.

Intake Id

Date AHI Form Submitted

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