Please note that information submitted will be used for referral to one of the following Life Lounge services: Counselling, CBT or the Mental Health advisor.

 

  • Have you accessed any of the well-being services within the Life Lounge previously?
  • What are the main reasons you want counselling? Please tick as many as are appropriate.
  • Have you had a history of emotional or mental health difficulties in the past?
  • Does any of your immediate family (biological mother, father grandparents or siblings) have a history of mental health difficulties?
  • Over the past two weeks have you been feeling nervous or on the edge?
  • Over the past two weeks have you found yourself not being able to stop or control worrying?
  • Over the past two weeks have you found yourself worrying too much about different things?
  • How much does your difficulty impact on you attending lectures, writing essays, sitting exams, attending placements, etc? Please rate on a scale of 0 - 8, 0 being 'Not at all' and 8 being 'Very Severely'.
  • How much does your difficulty impact on you cleaning, tidying, shopping, looking after the home / children etc? Please rate on a scale of 0 - 8, 0 being 'Not at all' and 8 being 'Very Severely'.
  • How much does your difficulty impact on you socialising with others, e.g. attending parties, pubs, outings, entertaining, etc? Please rate on a scale of 0 - 8, 0 being 'Not at all' and 8 being 'Very Severely'.
  • How much does your difficulty impact on you accessing leisure facilities on your own, e.g. reading, walking or other hobbies, etc? Please rate on a scale of 0 - 8, 0 being 'Not at all' and 8 being 'Very Severely'.
  • How much does your difficulty impact on you forming and maintaining relationships with others, e.g. class / flat mates, colleagues, etc? Please rate on a scale of 0 - 8, 0 being 'Not at all' and 8 being 'Very Severely'.
  • G.P. Address

 

The information held on your registration form is stored in accordance with the University Data Protection Policy. www.bolton.ac.uk/studentinformation-policyzone. This data is held and processed in accordance with the requirements of the Data Protection Act 1998. 

 

Webpage Last Updated November 2017.