Mental Health Support: Start Your ConsultationPlease complete this confidential form. Our clinician will review and respond shortly. Name * First Name Last Name Date Of Birth * MM DD YYYY Gender * Male Female Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Email * Phone * (###) ### #### Please take your time to answer the following questions about how you’ve been feeling. Your answers will help us understand the support you may need and whether treatment may be right for you. * Are you experiencing symptoms of: Depression Anxiety Both Not Sure In your own words, please describe how you’ve been feeling recently * How long have you been experiencing these feelings? * Less than 2 weeks 2–6 weeks 1–3 months Over 3 months Have these feelings affected your daily life (e.g., work, relationships, sleep)? * Yes No Have you experienced similar symptoms in the past? * Yes No These are standard tools used across the UK to help assess your mood. There are no right or wrong answers. * Little interest or pleasure in doing things Not at all Several Days More than half the days Nearly every day Feeling down, depressed, or hopeless * Not at all Several Days More than half the days Nearly every day Trouble falling or staying asleep, or sleeping too much * Not at all Several Days More than half the days Nearly every day Feeling tired or having little energy * Not at all Several Days More than half the days Nearly every day Poor appetite or overeating * Not at all Several Days More than half the days Nearly every day Feeling bad about yourself or that you are a failure * Not at all Several Days More than half the days Nearly every day Trouble concentrating on things * Not at all Several Days More than half the days Nearly every day Moving/speaking slowly or being fidgety/restless * Not at all Several Days More than half the days Nearly every day Thoughts that you'd be better off dead or of hurting yourself * Not at all Several Days More than half the days Nearly every day Feeling nervous, anxious, or on edge * Not at all Several Days More than half the days Nearly every day Not being able to stop or control worrying * Not at all Several Days More than half the days Nearly every day Worrying too much about different things * Not at all Several Days More than half the days Nearly every day Trouble relaxing * Not at all Several Days More than half the days Nearly every day Being so restless that it is hard to sit still * Not at all Several Days More than half the days Nearly every day Becoming easily annoyed or irritable * Not at all Several Days More than half the days Nearly every day Feeling afraid as if something awful might happen * Not at all Several Days More than half the days Nearly every day We ask these questions to ensure your safety and offer the right care. If you answer “yes” to any of these, we may recommend additional support or urgent care. * Have you had thoughts of harming yourself in the past 2 weeks? Yes No Have you ever made a plan or acted on thoughts of suicide or self-harm? * Yes No Do you have a trusted support network (friends, family, community)? * Yes No Are you currently under the care of a GP or mental health team? * Yes No Have you ever been diagnosed with a mental health condition? * Yes No If yes, please provide details (diagnosis, past treatments) Are you currently taking any medication for your mental health? * Yes No If yes, please list medication names and doses Have you previously tried any antidepressants or anti-anxiety medications? * Yes No If yes, please share what you’ve tried and how it went Are you open to exploring medication options now? * Yes No Are you currently pregnant or breastfeeding? * Yes No Not Applicable Do you have any known allergies to medications? * Yes No If yes, please specify Consent & Declaration * I confirm that the information provided is accurate and truthful. I understand this service is not a crisis service or emergency provider. I consent to my information being used for clinical care and prescribing. I am over 18 and aware of the risks and benefits of treatment. Are you registered with a GP? * Yes No GP Surgery Name Would you like us to send your consultation summary to your GP? * Yes No Consent & Declaration * I am over 18 and completing this for myself. I am not in crisis or at risk of self-harm. I understand this is a private, non-NHS service. I agree to seek urgent help if my condition worsens. I confirm my answers are truthful and complete. I consent to a prescriber reviewing my responses and sharing information with my GP if necessary. Thank you for completing your mental health consultation. A prescriber will review your answers with care and reach out shortly. You are not alone, and we’re here to support you. ⚠️ If you're feeling at immediate risk of harm or suicide, please do not wait. Contact Samaritans at 116 123 or call NHS 111. You can also go to your nearest A&E.We are here to support you, but some situations may need urgent or in-person care.
