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Cricket Referral
1.
Full Name:
2.
Date of Birth:
3.
Mobile Number:
4.
Email Address:
5.
Please provide the name and address of your GP (if known):
6.
Please check the box below if you are happy for us to contact your GP
I am happy for you to contact my GP
7.
Reason for contacting the service:
8.
Over the last 2 weeks, how often have you been bothered by any of the following problems?
Not at all
Several days
More than half the days
Nearly every day
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 over eating
Not at all
Several days
More than half the days
Nearly every day
Feeling bad about yourself or that you are a failure or have let yourself or your family down
Not at all
Several days
More than half the days
Nearly every day
Trouble concentrating on things such as reading the newspaper or watching television
Not at all
Several days
More than half the days
Nearly every day
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
Not at all
Several days
More than half the days
Nearly every day
Thoughts that you would be better off dead or hurting yourself in some way
Not at all
Several days
More than half the days
Nearly every day
9.
Over the last 2 weeks, how often have you been bothered by the following problems?
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
Please now submit your form below. We will be in touch as soon as possible. If urgent, please contact NHS 24 on 111.