Sanibel - Opting in to our Service

	e: admin@sanibel.org.uk \| t: 020 8532 2370 \| f: 020 8532 2379
	Sanibel Psychological Therapies is a registered charity (number 1133652, England and Wales) and a company limited by guarantee (number 7037120, England and Wales). Registered office: Lily House, 11 The Shrubberies, George Lane, South Woodford, London E18 1BD

To access our service you will need your reference number, found on the right hand side of your letter

Please complete the form below. Fields marked * are mandatory

· When you have finished, click the “Submit Form” and an email will be sent to you confirming your place on the waiting list.

· We will then contact you by telephone to arrange an appointment so please make sure you have a private contact number submitted.

*First Name & Surname:

*Client ID (Number is on the right hand side of your letter)

*Private Email Address:

*Contact number MUST be provided so we can call to arrange your appointment (Mobile Phone if possible)

If any of your address details are incorrect, please write changes below:

*Please identify ethnicity:

White British
Asian or British Asian - Indian
Asian or British Asian - Pakistani
Asian or British Asian - Bangladeshi
Black or Black British - Caribbean
Black or Black British - African
Turkish
Mixed White and Black Caribbean
Mixed White and Black African
Mixed White and Asian
Asian or British Asian - Chinese
White Irish
Eastern European
Other

Other (Please state):

*Please complete the questions below which help us to prepare for your first visit (all questions mandatory):

About your difficulties

Please select, in order of severity, your current difficulties:
1st (Mandatory)*
2nd (Optional)
3rd (Optional)

*Depression Questionnaire

Over the last two weeks, how often have you been bothered by the following?	Not at all	Several days	More than half the days	Nearly every day
Little interest or pleasure in doing things
Feeling down, depressed or hopeless
Trouble falling or staying asleep, or sleeping too much
Feeling tired or having little energy
Poor appetite or overeating
Feeling bad about yourself – or that you are a failure or have let yourself or your family down
Trouble concentrating on things, such as reading the newspaper or watching television
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
Thoughts that you would be better off dead or of hurting yourself in some way

*Anxiety Questionnaire

Over the last two weeks, how often have you been bothered by the following?	Not at all	Several days	More than half the days	Nearly every day
Feeling nervous, anxious or on edge
Not being able to stop or control worrying
Worrying too much about different things
Trouble relaxing
Being so restless that it is hard to sit still
Becoming easily annoyed or irritable
Feeling afraid as if something awful might happen

*Phobias

On a scale of 0 to 8, how much would you avoid the following situations	Not avoid 0	1	2	3	4	5	6	7	Always avoid 8
Social situations due to a fear of being embarrassed or making a fool of myself
Certain situations because of a fear of having a panic attack or other distressing symptoms (such as loss of bladder control, vomiting or dizziness)
Certain situations because of a fear of particular objects or activities (such as animals, heights, seeing blood, being in confined spaces, driving or flying).

*Employment/Medication

Please indicate which of the following options best describes your current status
	Yes	No
Are you taking medication for your psychological difficulties?
Are you currently receiving Statutory Sick Pay?
Are you currently receiving Job Seekers Allowance, Income support or Incapacity benefit?

*Work & Social Adjustment

People's problems sometimes affect their ability to do certain day-to-day tasks in their lives. To rate your problems look at each section and determine on the scale provided how much your problem impairs your ability to carry out the activity.
Scale is 0 = Not at all and 8 = Very severely	0	1	2	3	4	5	6	7	8
WORK - if you are retired or choose not to have a job for reasons unrelated to your problem, please select 0 (not applicable)
HOME MANAGEMENT - Cleaning, tidying, shopping, cooking, looking after home/children, paying bills etc.
SOCIAL LEISURE ACTIVITIES - With other people, e.g. parties, pubs, outings, entertaining etc.
PRIVATE LEISURE ACTIVITIES – Done alone, e.g. reading, gardening, sewing, hobbies, walking etc.
FAMILY AND RELATIONSHIPS – Form and maintain close relationships with others including the people that I live with

Please state any special requirements here: