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The survey will take approximately 5 minutes to complete.

Thank you for taking the time to complete these questions - the answers you give help us understand your current needs so we can ensure we offer the right service.

We ask you to be open and honest - none of your information is shared other than within the Birchall referrals team.

If you are a parent/carer or professional completing the form on behalf of a child or young person then, in each question,  please replace 'you' with the  'child or young person'.

Many thanks.

How often do you have upsetting thoughts or pictures that pop into your head about what has happened?
How often do you have bad dreams reminding you of what happened?
How often do you feel as if what has happened is happening all over again?
How often do you feel upset when something reminds you of what happened?
How often do you have strong feelings in your body such as upset stomach, heart beating fast, sweating when you are reminded of what happened?
How often do you try not to think about or have feelings about what happened?
How often do you stay away from people, places, things or situations that remind you of what happened?
How often are you not able to remember part of what happened?
How often do you have negative thought about yourself or others - things such as thinking you wont have a good life, you cant trust anyone or the world feels unsafe?
How often do you blame yourself for what happened or blame someone else when it wasn't their fault?
How often do you have bad feelings such as being afraid, angry, guilty or ashamed?
How often do you not want to do things you used to enjoy doing?
How often do you not feel close to other people, you don't want contact with other people?
How often do you feel mad, have fits of anger and take it out on others?
How often do you do unsafe things that might put you at risk?
How often are you overly careful, on your guard, checking to see who might be around you?
How often are you jumpy or easily startled?
How often do you find it hard to pay attention or concentrate on things?
How often do you have trouble falling or staying asleep?
Do you ever take drugs or drink a lot of alcohol?
Have you ever thought that you don't want to be alive?
Have you acted on your thoughts around suicide in the last 3 months?
Is attending counselling at this time your own decision?
Are you able to commit the time needed and attend weekly appointments?
Are you currently living in a safe enough place to be able to engage?
Do you feel ready to engage in counselling and explore and reflect on yourself?
Are you able to cope with strong feelings and memories that attending counselling may bring up?

Thanks for your submission, we will be in contact soon.

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