top of page
Street Art

REFERRAL NEEDS ASSESSMENT - ADULTS (18+)

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.

Many thanks.

How often do you have repeated, disturbing and unwanted memories of your stressful experience?
How often do you have disturbing dreams about your stressful experience?
How often do you suddenly feel or act as if your experience were actually happening again - you are reliving your experience?
How often do you feel upset when something reminds you of your experience?
How often do you have a strong physical reaction such as a pounding heart, trouble breathing, sweating when something reminds you of your experience?
How often do you avoid memories, thoughts or feelings related the your stressful experience?
How often do you avoid external reminders such as people, places, conversations, objects or situations that remind you of your experience?
How often do you have trouble recalling important parts of your experience?
How often do you have strong negative thoughts about yourself, others or the world - such as 'I am bad', 'there is something seriously wrong with me', 'no-one can be trusted', 'the world is completely dangerous'?
How often do you blame yourself or someone else for your experience or what happened after it?
How often do you have strong negative feelings such as fear, horror, anger guilt or shame?
Have you lost interest in activities you used to enjoy?
Do you feel distant or cut off from other people?
How often do you have trouble experiencing positive feelings, being unable to feel happiness or have loving feelings towards those close to you?
How often do you display irritable behaviour, angry outbursts or act aggressively?
How often do you take too many risks or do things that could cause you harm?
How often do you feel super alert, watchful or on-guard?
How often do you feel jumpy or are easily startled?
How often do you have difficulty concentrating?
How often do you have trouble falling or staying asleep?
Do you have any issues with drugs or alcohol?
How often do you have suicidal thoughts?
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.

bottom of page