Aviva Triage Review

The following information has been entered by the Patient, you cannot change these answers.

Innovate Healthcare Reference:

Referrer Name:

Referrer Surname:

Referrer reference:

Referrer email address:

First Name:*

Surname:*

Email Address:*

Date of birth:*

GP name:*

Surgery name:*

Surgery address:*

Surgery phone number:*

Are you currently taking any medication for your mental health e.g. anti-depressants; anti-anxiety medication?*

No
Yes

If known, what is the name of the medication and the dosage?

1. Feeling nervous, anxious, or on edge:*

Not at all
Several days
More than half the days
Nearly every day

2. Not being able to stop or control worrying*

Not at all
Several days
More than half the days
Nearly every day

3. Worrying too much about different things*

Not at all
Several days
More than half the days
Nearly every day

4. Trouble relaxing*

Not at all
Several days
More than half the days
Nearly every day

5. Being so restless that it is hard to sit still*

Not at all
Several days
More than half the days
Nearly every day

6. Becoming easily annoyed or irritable*

Not at all
Several days
More than half the days
Nearly every day

7. Feeling afraid, as if something awful might happen*

Not at all
Several days
More than half the days
Nearly every day

Anxiety – GAD 7:

1. Little interest or pleasure in doing things*

Not at all
Several days
ore than half the days
Nearly every day

2. Feeling down, depressed, or hopeless*

Not at all
Several days
More than half the days
Nearly every day

3. Trouble falling/staying asleep, sleeping too much*

Not at all
Several days
More than half the days
Nearly every day

4. Feeling tired or having little energy*

Not at all
Several days
More than half the days
Nearly every day

5. Poor appetite or overeating*

Not at all
Several days
More than half the days
Nearly every day

6. 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

7. 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

8. 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

9. 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

Innovate does not operate a service for mental health emergencies. In an emergency, please contact your GP, NHS Choices on 111, the Samaritans on 116 123, or the Accident and Emergency Department of your local Hospital or NHS Trust.

I understand the above statement:

I understand the above statement:

Low mood/Depression – PHQ9:

Do you use recreational drugs?*

No
Yes

Please provide further information:*

How many units of alcohol do you drink per week?*

Please give a brief summary of the ONE MAIN overwhelming event/incident on which you are basing your scores:*

1. Any reminder brought back feelings about it:*

2. I had trouble staying asleep:*

3. Other things kept making me think about it:*

4. I felt irritable and angry:*

5. I avoided letting myself get upset when I thought about it or was reminded of it:*

6. I thought about it when I didn’t mean to:*

7. I felt as if it hadn’t happened or wasn’t real:*

8. I stayed away from reminders about it:*

9. Pictures about it popped into my mind:*

10. I was jumpy and easily startled:*

11. I tried not to think about it:*

12. I was aware that I still had a lot of feelings about it, but I didn’t deal with them:*

13. My feelings about it were kind of numb:*

14. I found myself acting or feeling as though I was back at that time:*

15. I had trouble falling asleep:*

16. I had waves of strong feelings about it:*

17. I tried to remove it from my memory:*

18. I had trouble concentrating:*

19. Reminders of it caused me to have physical reactions, such as sweating, trouble breathing, nausea, or a pounding heart:*

20. I had dreams about it:*

21. I felt watchful or on-guard:*

22. I tried not to talk about it:*

Impact of Events Scale – Revised:

Have you ever had a diagnosis from a Psychologist, Psychiatrist, or Mental Health Nurse for a severe/complex mental health condition?*

No
Yes

If Yes what was diagnosed, and approx. when?*

Have you ever experienced any common mental health issues such as Anxiety and/or Depression*

No
Yes

If Yes please comment:*

Have you had any therapy before?*

No
Yes

Which form of therapy did you have:*

Please specify:*

If Yes to the above what did you find helpful/unhelpful regarding your past experience of therapy?*

What is the main issue that is causing you the most distress at present, that you would like to prioritise working on now?*

How long have you been feeling distressed about this particular issue which you would now like to prioritise working on now?*

What do you hope to achieve in Psychological therapy sessions now?*

Would you be able to commit to regular (weekly) video therapy sessions?*

Treatment Recommended:

No
Yes

Practitioner Name:*

Date completed:

Rationale:*

PSYCHOLOGICAL TRIAGE - Review Aviva

The following information has been entered by the Patient, you cannot change these answers.

Innovate does not operate a service for mental health emergencies. In an emergency, please contact your GP, NHS Choices on 111, the Samaritans on 116 123, or the Accident and Emergency Department of your local Hospital or NHS Trust.