Wellbeing Hub Self Referral

To submit your Wellbeing Hub Self Referral, please complete the online form by answering each of the following questions. All fields marked * are required fields and must be completed. On submission a PDF summary of your completed form shall be emailed to GO Health Services and a copy sent to your own email address.

The information provided will be retained by GO Health Services and will be held on a secure database and will not be used for any other purpose without your consent. Please note however some information may be shared for statistical purposes only which will not identify individuals.

For further information please visit https://gohealthservices.scot.nhs.uk/wellbeing.

This form is also available in other formats and languages, upon request. Please Please call NHS Grampian Corporate Communications on (01224) 551116 or (01224) 552245 for further information.

Please be aware that we are not a crisis or emergency service. If you feel you are becoming more unwell and you are not sure you can keep yourself safe please contact your GP, NHS24 (111), Samaritans (116 123) or Breathing Space (0800 83 85 87) for support and advice.

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SECTION 1: PERSONAL DETAILS

Forename *

Surname *

Date of Birth *

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Email Address (NHS if accessible) *

Email

Confirm Email

Main Contact Number *

Second Contact Number

Best Contact Day * MondayTuesdayWednesdayThursdayFridayAny Day (Monday – Friday)

Best Contact Time * Morning (8am – 12noon)Afternoon (12noon – 4pm)Any Time (8am – 4pm)

Address for Correspondence *

Postcode *

Name of GP

GP Practice * Not Known / Not Registered with GPOTHER – Please SpecifyAberchirder Medical PracticeAberlour Health CentreAboyne Health CentreAden Health CentreAlbyn Medical PracticeAlford Medical PracticeAn Caorann Medical PracticeArdach Health CentreAuchenblae Medical CentreBallater ClinicBanchory Group PracticeBanff & Gamrie Medical PracticeBraemar Health ClinicBrechin Health CentreBucksburn Medical PracticeBydand Medical GroupCalsayseat Medical GroupCamphill Medical PracticeCentral Buchan Medical PracticeCove Bay Health CentreCrimmond Medical CentreCruden Bay SurgeryCruden Medical GroupCullen Medical CentreCults Medical GroupCuminestownDanestone Medical PracticeDenburn Medical CentreElgin Community SurgeryEllon Group PracticeElmbank Group PracticeFinlayson Street SurgeryFochabers Medical PracticeForres Health CentreFyvie Old Meldrum Medical GroupGarthdee Medical PracticeGilbert Road Medical GroupGlenlivet Medical PracticeGreat Western Medical PracticeHaddo Medical GroupHamilton Medical GroupHolburn Medical GroupInsch Medical PracticeInverbervie Medical GroupInverurie Medical GroupJesmond SurgeryKeith Medical GroupKemnay Medical GroupKincorth Medical PracticeKingswell Medical PracticeKintore Medical CentreLaurencekirk Medical GroupLinks Medical Practice, AberdeenLinkwood MedicalMacduff Medical PracticeMaryhill Health CentreMaud SurgeryMintlaw Group PracticeMoray Coast Medical PracticeNew Deer Medical PracticeNew Dyce Medical PracticeNewburn Health CentreNorthfield & Mastrick Medical PracticeOld Aberdeen Medical PracticeOld Machar Medical PracticePeterculter Medical PracticePeterhead Medical CentrePortlethen Medical CentreRhynie SurgeryRinnes Medical GroupRothes Medical CentreRubislaw Place Medical GroupSaltoun SurgeryScotstown Medical GroupSeafield Medical CentreSkene Medical GroupStonehaven Medical GroupStrathdon Medical CentreStrichen SurgeryTarland SurgeryTomintoul Medical CentreTorphins Medical PracticeTorry Medical PracticeTorry Neighbourhood CentreTurriff Medical PracticeVaris Medical PracticeVictoria Street Medical GroupWestburn Medical GroupWhinhill Medical PracticeWoodside Medical Group, Aberdeen

Other GP Practice

As part of our Wellbeing Referral Process, we notify the client's GP they have requested support and are now on the waiting list for the appropriate service. The purpose of this is only to inform and we do not ask the GP to supply medical information. Clients have the right to OPT IN or OPT OUT of having their GP informed. Please state your preference. * OPT INOPT OUT

Name of Emergency Contact *

Contact Number of Emergency Contact *

Employer * NHSSocial Care (Health and Social Care employees only)3rd Sector

Which area is your employer based in? * GrampianOrkneyShetlandOther (specify below)

Other Health Board *

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SECTION 2: REFERRAL DETAILS

What do you consider are your main current difficulties that have led you to self-refer to the Wellbeing Hub? *

Please provide details of symptoms you are experiencing that indicate reduced wellbeing and the impact these are having on you and you’re functioning.

What do you think has contributed to these difficulties? *

This may involve changes in social experiences, health matters, work situations or family functioning. Please provide information that you think is relevant to your current situation.

How are your current difficulties impacting upon your work functioning? *

Please note that we can only offer services to individuals where wellbeing difficulties are impacting upon your work functioning.

Please provide details of any other service you are involved with currently that supports your wellbeing (or put none) *

Please provide details of what you have done or are doing to support your wellbeing since your difficulties started (please select all that are relevant) *

• Computerised CBT Course
• Self-Care Apps
• Self-Help Guides/Books
• Meditation/Mindfulness Practice
• Breathing/Relaxation Practice
• Regular Exercise
• Activity Planning
• Increased Social Connections
• Counselling
• Psychological Therapy
• Medication
• Alternative Treatments

What are your hopes and goals from engaging with our service? *

If you are hoping to engage in therapeutic sessions with the Wellbeing Hub, please give details of what you are hoping to change or achieve.

Please provide details on any previous experience of therapeutic support you have received and explain in what ways this was experienced useful or not to you *

We require our clients to engage in a course of regular sessions. At times clients may be asked to complete therapeutic tasks or engage in structured reflection outside of sessions. Are there any obstacles to being able to meet these requirements that requires consideration? *

Please write down any further information that you think may be relevant, or questions that you may have about our service that you would like to discuss further in your wellbeing call *

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SECTION 3: HEALTH QUESTIONNAIRES (please complete both)

PHQ9 – Patient Health Questionnaire

OVER THE LAST TWO WEEKS, how often have you been bothered by the following problems (please select one option from the dropdown for each problem)?

A. Little interest or pleasure in doing things * 0 – Not at all1 – Several days2 – More than half the days3 – Nearly every day

B. Feeling down, depressed or hopeless * 0 – Not at all1 – Several days2 – More than half the days3 – Nearly every day

C. Trouble falling or staying asleep, sleeping too much * 0 – Not at all1 – Several days2 – More than half the days3 – Nearly every day

D. Feeling tired or having little energy * 0 – Not at all1 – Several days2 – More than half the days3 – Nearly every day

E. Poor appetite or overeating * 0 – Not at all1 – Several days2 – More than half the days3 – Nearly every day

F. Feeling bad about yourself – or that you are a failure or have let yourself or your family down * 0 – Not at all1 – Several days2 – More than half the days3 – Nearly every day

G. Trouble concentrating on things, such as reading the newspaper or watching television * 0 – Not at all1 – Several days2 – More than half the days3 – Nearly every day

H. 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 * 0 – Not at all1 – Several days2 – More than half the days3 – Nearly every day

I. Thoughts that you would be better off dead or of hurting yourself in some way * 0 – Not at all1 – Several days2 – More than half the days3 – Nearly every day

If you scored more than 1 for any of the problems above, how difficult have these problems made it for you to do your work , take care of things at home or get along with other people? Not difficult at allSomewhat difficultVery difficultExtremely difficult

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GAD7 – General Anxiety Questionnaire

OVER THE LAST TWO WEEKS, how often have you been bothered by the following problems (please select one option from the dropdown for each problem)?

A. Feeling nervous, anxious or on edge * 0 – Not at all1 – Several days2 – More than half the days3 – Nearly every day

B. Not being able to stop or control worrying * 0 – Not at all1 – Several days2 – More than half the days3 – Nearly every day

C. Worrying too much about different things * 0 – Not at all1 – Several days2 – More than half the days3 – Nearly every day

D. Trouble relaxing * 0 – Not at all1 – Several days2 – More than half the days3 – Nearly every day

E. Being so restless that its hard to sit still * 0 – Not at all1 – Several days2 – More than half the days3 – Nearly every day

F. Becoming easily annoyed or irritable * 0 – Not at all1 – Several days2 – More than half the days3 – Nearly every day

G. Feeling afraid as if something awful might happen * 0 – Not at all1 – Several days2 – More than half the days3 – Nearly every day

If you scored more than 1 for any of the problems above, how difficult have these problems made it for you to do your work , take care of things at home or get along with other people? Not difficult at allSomewhat difficultVery difficultExtremely difficult

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