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Bring & Buy sale to raise money for Ukrainians March 2022
Ukrainian Refuee Event - cards, cuppa and cakes - March 2022
Quiz Night March 2022
AGM March 2022
SPACE @ Lepe Beach 2021
Murder Mystery 2019
SPACE
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SPACE Referral Form
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Indicates required field
Title
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Select One
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Mrs
Miss
Mx
Dr
Rev
Prof
Select One
Date of birth
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Address
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State
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Nationality
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Ethnicity
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Name
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Gender
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Select one
Male
Female
Other
Email
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Mobile Number
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Can a Voicemail be left on this number?
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Can a SMS be sent to this number?
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GP Name
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GP Number
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GP Address
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City
State
Zip Code
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Could you give us a outline of the main problem that you are having difficulty with / the reason you have referred?
*
What do you hope to gain from attending SPACE?
*
PHQ_9 Over the last two weeks how often have you been bothered by the following problems?
Little interest or pleasure in doing things
*
Not at all
Several Days
More than half the days
Nearly every day
Trouble falling or staying asleep, sleeping too much
*
Not at all
Several Days
More than half the days
Nearly every day
Poor appetite or overeating
*
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
Thoughts that you would be better off dead or of hurting yourself in some way
*
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
Feeling tired or having little energy
*
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
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
CAD-7 Over the last two weeks how often have you been bothered by the following problems?
Feeling nervous, anxious, or on edge
*
Not at all
Several Days
Over than half the days
Nearly every day
Worrying too much about different things
*
Not at all
Several Days
Over than half the days
Nearly every day
Being so restless that it’s hard to sit still
*
Not at all
Several Days
Over than half the days
Nearly every day
Not being able to stop or control worrying
*
Not at all
Several Days
Over than half the days
Nearly every day
Trouble relaxing
*
Not at all
Several Days
Over than half the days
Nearly every day
Becoming easily annoyed or irritable
*
Not at all
Several Days
Over than half the days
Nearly every day
Feeling afraid as if something awful might happen
*
Not at all
Several Days
Over than half the days
Nearly every day
Are you currently involved with other mental health services? Select all that apply:
*
Addiction & Substance support
Bereavement services
Community mental health team (CMHT)
Crisis team
Early intervention Psychosis team (EIP)
Eating disorder service
Inpatient service
Private treatment
Psychiatrist
Psychologist
Relationship Counselling
I am currently a creative option service user
*
Yes
No
Have you attend space before?
*
Yes
No
Other? Please specify
*
Submit
Home
About
History
The Service
Team Members
Acknowledgements
Constitution
Membership Form
Rule Book
What's On
Events
Bring & Buy sale to raise money for Ukrainians March 2022
Ukrainian Refuee Event - cards, cuppa and cakes - March 2022
Quiz Night March 2022
AGM March 2022
SPACE @ Lepe Beach 2021
Murder Mystery 2019
SPACE
Get Involved
Newcomers
Volunteers
Committee
Blog
Contact