Intake Form Spam protection, skip this field IMPORTANT INSTRUCTIONS (optional) If you have not spoken to anyone at Icarus, please do so before completing the intake form, this enables us to keep track of new intakes and allocate you an apprpriate therapist. If this is the case, please call Icarus on 0333 987 5055. If you have already spoken with someone then please complete this form as fully as possible and be open and honest with your answers, this will enable your therapist to have a good understanding to begin treatment with you. PERSONAL DETAILS Name Address Email Phone Date of Birth SERVICE DETAILS Are you? Choose Civillian Military Police Fire Service Prison Service NHS Which Military Service? Choose RN RM Army RAF Reserves Service Status Choose Serving Retired Veteran Service Number Date Enlisted Date Discharged NEXT OF KIN DETAILS Next of Kin - Name Next of Kin - Telephone Number Next of Kin - Address & Postcode Next of Kin - Relationship Choose Mother Father Wife Husband Partner Other Next of Kin - If other, please specify GP DETAILS GP Name GP Phone Number GP Medical Practice Address & Postcode GENERAL PHYSICAL & MENTAL HEALTH HISTORY 1. How would you rate your current physical health? Choose Poor Unsatisfactory Satisfactory Good Very good Please list any specific physical problems you are currently experiencing 2. How would you rate your current sleeping habits? Choose Poor Unsatisfactory Satisfactory Good Very good Please list any specific sleep problems you are currently experiencing 3. How many times per week do you generally exercise? What types of exercise do you take part in? 4. Please list any difficulties you experience with your appetite or eating patterns 5. Are you currently experiencing overwhelming sadness, grief, or depression? Yes No If Yes, please explain how long you have been experiencing this and the cause, if known? 6. Are you currently experiencing anxiety, panic attacks,or have any phobias? Yes No If Yes, please explain how long you have been experiencing this and the cause, if known? 7. Are you currently experiencing any chronic pain? Yes No If Yes, please explain how long you have been experiencing this and the cause, if known? 8. Do you drink alcohol more than once a week? Yes No If Yes, how many units per week? 9. How often do you engage in recreational drug use? Daily Weekly Monthly Infrequently Never If Yes, what do you use? 10. Are you currently in a romantic relationship? Yes No On a scale of 1-10, how would you rate your relationship? 10 11. What significant life changes or stressful events have you experienced recently? MENTAL HEALTH Please answer as the following questions as best you can. Have you previously received any type of mental health services (psychotherapy, psychiatric services, etc.)? Yes No If Yes, please provide details of type of treatment and dates if you can Have you ever been prescribed psychiatric medication? Yes No If Yes, please provide details of medications, dosages and dates if you can Are you currently taking any prescription medication? Yes No If Yes, please provide details of medications, dosages and dates started if you can MENTAL HEALTH ASSESSMENTS GAD-7 ANXIETY Please select one answer for each question 1. Feeling nervous, anxious or on edge Choose Not at all Several days More than half the days Nearly every day 2. Not being able to stop or control worrying Choose Not at all Several days More than half the days Nearly every day 3. Worrying too much about different things Choose Not at all Several days More than half the days Nearly every day 4. Trouble relaxing Choose Not at all Several days More than half the days Nearly every day 5. Being so restless that it is hard to sit still Choose Not at all Several days More than half the days Nearly every day 6. Becoming easily annoyed or irritable Choose Not at all Several days More than half the days Nearly every day 7. Feeling afraid as if something awful might happen Choose Not at all Several days More than half the days Nearly every day If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people? Choose Not difficult at all Somewhat difficult Very difficult Extremely difficult PHQ-9 DEPRESSION Please select one answer for each question 1. Little interest or pleasure in doing things Choose Not at all Several days More than half the days Nearly every day 2. Feeling down, depressed, or hopeless Choose Not at all Several days More than half the days Nearly every day 3. Trouble falling or staying asleep, or sleeping too much Choose Not at all Several days More than half the days Nearly every day 4. Feeling tired or having little energy Choose Not at all Several days More than half the days Nearly every day 5. Poor appetite or overeating Choose Not at all Several days More than half the days Nearly every day 6. Feeling bad about yourself — or that you are a failure or have let yourself or your family down Choose Not at all Several days More than half the days Nearly every day 7. Trouble concentrating on things, such as reading the newspaper or watching television Choose Not at all Several days More than half the days Nearly every day 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 Choose Not at all Several days More than half the days Nearly every day 9. Thoughts that you would be better off dead or of hurting yourself in some way Choose Not at all Several days More than half the days Nearly every day WORK AND SOCIAL ADJUSTMENT SCALE (WSAS) Please Select One Answer For Each Question Mental health can affect one's ability to do certain day-to-day tasks in their lives. Please read each item below and respond based on how much your mental health impairs your ability to carry out the activity. 1. Because of my mental health my ability to work is impaired. ‘0’ means ‘not at all impaired’ and ‘8’ means very severely impaired to the point I can't work Choose 0. Not at all 1. 2. Slightly 3. 4. Definitely 5. 6. Markedly 7. 8. Very severly 2. Because of my mental health my home management (cleaning, tidying, shopping, cooking, looking after home or children, paying bills) is impaired Choose 0. Not at all 1. 2. Slightly 3. 4. Definitely 5. 6. Markedly 7. 8. Very severely 3. Because of my mental health my social leisure activities (with other people e.g. parties, bars, clubs, outings, visits, dating, home entertaining) are impaired Choose 0. Not at all 1. 2. Slightly 3. 4. Definitely 5. 6. Markedly 7. 8. Very severely 4. Because of my mental health, my private leisure activities (done alone, such as reading, gardening, collecting, sewing, walking alone) are impaired Choose 0. Not at all 1. 2. Slightly 3. 4. Definitely 5. 6. Markedly 7. 8. Very severely 5. Because of my mental health, my ability to form and maintain close relationships with others, including those I live with, is impaired Choose 0. Not at all 1. 2. Slightly 3. 4. Definitely 5. 6. Markedly 7. 8. Very severely ADDITIONAL INFORMATION 1. Are you currently employed? Yes No If yes, what do you currently do and are you happy with your job? 2. Do you consider yourself to be spiritual or religious? Yes No If yes, what is your faith or spiritual belief? 3. What is the most important thing we can do to help you right now? 4. Are you 100% committed to doing everything we ask of you and work with us to help you? Yes No 5. How did you hear about Icarus Choose GP Psychologist Psychiatrist Friend Combat Stress Help for Heroes RBL SSAFA Legion Scotland The Veterans Charity Project Nova Helping Homeless Veterans-UK Other 6. Please Provide details of the Other Person or Organisation so that we can thank them 7. Informed Consent I have read and agree to the terms and conditions of the Informed Consent Validate your form Save draft
