← Back Qualified Counsellor - Service Evaluation Your details First Name Last Name Address line 1 (door number) Street Name City Post Code Mobile Email Date of Birth EligibilityA few quick questions to check the scheme is the right fit. YesNoBlack Heritage EligibilityYesNoOver 18YesNoUK ResidentYesNoLondon/Birmingham ResidentYesNo Your circumstances Employment Status--None--Paid work: full time Paid work: part time Self employed Full-time education Out of work — registered unemployed Out of work — unregistered unemployed Unemployed — permanently sick or disabled Not working for domestic reasons Retired Other Household Income--None--Under £15,000 £15,000–£20,000 £20,000–£30,000 £30,000–£40,000 £40,000+ Receiving Benefits--None--Universal Credit Housing Benefit PIP ESA Carer's Allowance Child Benefit Pension Credit None YesNoAble to Pay BillsYesNoCan Afford FoodYesNoCan Afford TransportYesNoCan Afford CounsellingYesNo Your wellbeingThere are no right or wrong answers, just answer as honestly as you can. YesNoSpoken to GPYesNoCurrent CounsellingYesNoPrevious CounsellingYesNoWaiting List SupportYesNo None of the timeRarelySome of the timeOftenAll of the timeFuture OptimismNone of the timeRarelySome of the timeOftenAll of the timeFeeling UsefulNone of the timeRarelySome of the timeOftenAll of the timeFeeling RelaxedNone of the timeRarelySome of the timeOftenAll of the timeInterested in OthersNone of the timeRarelySome of the timeOftenAll of the timeEnergy LevelNone of the timeRarelySome of the timeOftenAll of the timeProblem ManagementNone of the timeRarelySome of the timeOftenAll of the timeThinking ClearlyNone of the timeRarelySome of the timeOftenAll of the time Self Confidence--None--None of the time Rarely Some of the time Often · All of the time None of the timeRarelySome of the timeOftenAll of the timeClose to OthersNone of the timeRarelySome of the timeOftenAll of the timeFeeling ConfidentNone of the timeRarelySome of the timeOftenAll of the timeDecision MakingNone of the timeRarelySome of the timeOftenAll of the timeFeeling LovedNone of the timeRarelySome of the timeOftenAll of the timeInterest in New ThingsNone of the timeRarelySome of the timeOftenAll of the timeFeeling CheerfulNone of the timeRarelySome of the timeOftenAll of the time Your safetyThis helps us make sure you get the right level of support. Self Harm Thoughts--None--Never Sometimes Often Most days Self Harm Plan--None--No plans Vague thoughts of how A clear plan Currently Safe Yes No Safety Details Psychiatric Involvement Mental Health Admission Mental Health Diagnosis Commitment and availability YesNoCommit 15 SessionsYesNoWeekly AvailabilityYesNoOnline Session ReadyYesNo Application Reason Expected Outcome Allocation Notes Disability Yes No Assistance Required Consent and declarationsPlease read each line carefully before continuing. YesNoGP Contact ConsentYesNoAlternative Pathway ConsentYesNoMonitoring ConsentYesNoContact ConsentYesNoFollow-up ConsentYesNoInformation DeclarationYesNoUK Residency ConfirmationYesNoChange Notification AgreementYesNoAccuracy AcknowledgementYesNoMarketing Opt-InYesNo Referral Source--None--Instagram TMAF website Search engine Email Recommended by a charity Recommended by family/friend Social media Other