Mental Health Review

Mental Health Form

This form is designed for patients who have mild anxiety and/or depression symptoms to help you consider factors affecting your mental health and inform you about self-care and the management options available.

If you have thoughts of ending your life/self harm /suicide/harming others please call us for an assessment urgently. Do not use this form. you can also the contact crisis team out of hours.

First Name *

Last Name *

Date of Birth

Please use format day/month/year e.g. 12/05/1979

Email *

Enter Email

Phone Number *

What symptoms do you have?

How does this impact on day to day activities?

Do you use alcohol or drugs? If yes please give details.

How have you tried to help yourself? If yes please give details.

Would you consider CBT or therapy to help your symptoms?

Yes

Medications can be considered. Is this something you would like to know more about?

Yes

Privacy Policy

This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data.

I consent to the practice collecting and storing my data from this form.

Website/URL

If you are human, leave this field blank.