Talking Therapies

Useful information and questionnaires to be completed prior to your first session

Consent form

Consent for Hull and East Yorkshire Mind to share and use my information

What are we asking you to do?

We would like to help you, however to do this we sometimes need to share your personal details e.g., date of birth, name and address, health issues, ethnicity, medication, etc. as well as information about the support you receive from us and the main thing that worries you. This will help us to make sure you get the support you need.

Do I have to fill out the consent form?

It is important for you to fill out the form, even if you choose to not share any of your personal information. We are legally required to keep a record of the decision you make about who can or can’t share your data with. This form will be a clear record of your decision about your data.

Do I have to agree to consent?

We can still offer you the additional support if you don’t agree to share any of your personal details, but we may not be able to offer you the best support available if we cannot share your information with other local services.

We will only disclose your information to those third parties which you have consented to us contacting, except in the following circumstances:

  • if we consider that your health and safety is at risk or there appears to be child protection or vulnerable adult protection issues;
  • if we have reason to believe unlawful or potentially harmful activities are taking place;
  • if we are permitted or required by law to disclose such information; or
  • if we consider there to be a risk of suicide or self-harm if the information is not disclosed

What if I change my mind later on?

You have the right to withdraw consent in part or fully at any time either verbally or in writing. You can also agree later to give consent on something you have not wanted sharing or withdrawn consent for previously.

    Young Person's Name (required)

    Young Person's Date of Birth: (required)

    Parent / Carers Name (required)

    Parent / Carers Date of Birth: (required)

    Date (required)

    Phone Number (required)

    Email Address (required)

    I give permission for staff at Hull and East Yorkshire Mind to discuss any aspect of my care and support needs with the following: (required)

    Is there an agency or anyone who you do not wish us to contact(required)

    If yes, who?

    By submitting this form, I agree that Hull & East Yorkshire Mind may discuss my support with the agencies I have indicated above, acknowledge the circumstances in which information may be disclosed without my consent, and agree to my personal data being used and processed.

    Please complete both questionnaires below, answering all the questions in order to progress your referral

    Children and Young People - RCADS questionnaire

    The Young Person should complete this form independently and ALL fields must be completed. Please select the word that shows how often each of these things happens to you. There are no right or wrong answers.

      Your name: (required)

      Date of Birth: (required)

      Date (required)

      I worry about things (required)

      I feel sad or empty (required)

      When I have a problem, I get a funny feeling in my stomach (required)

      I worry when I think that I have done poorly at something (required)

      I feel afraid of being home alone (required)

      Nothing is much fun anymore (required)

      I feel scared when taking a test (required)

      I worry when I think someone is angry with me (required)

      I worry about being away from my parent (required)

      I am bothered by bad or silly thoughts in my mind (required)

      I have trouble sleeping (required)

      I worry about doing badly at school work (required)

      I worry that something awful will happen to someone in the family (required)

      I suddenly feel like I can’t breathe when there is no reason for this (required)

      I have problems with my appetite (required)

      I have to keep checking that things are done right (like turning the switch off, or the door is locked) (required)

      I feel scared to sleep on my own (required)

      I have trouble going to school in the morning as I am nervous or afraid (required)

      I have no energy for things (required)

      I worry about looking foolish (required)

      I am tired a lot (required)

      I worry that bad things will happen to me (required)

      I can’t seem to get bad or silly thoughts out of my head (required)

      When I have a problem, my heart beats really fast (required)

      I cannot think clearly (required)

      I suddenly starts to tremble or shake when there is no reason for this (required)

      I worry that something bad will happen to me (required)

      When I have a problem, I feel shaky (required)

      I feel worthless (required)

      I worry about making mistakes (required)

      I have to think of special thoughts (like numbers or words) to stop bad things from happening (required)

      I worry what other people think of me (required)

      I am afraid of being in crowded places (like shopping centers, the movies, buses, busy playgrounds) (required)

      All of a sudden I will feel really scared for no reasons at all (required)

      I worry about what is going to happen (required)

      I suddenly become dizzy or faint when there is no reason for this (required)

      I think about death (required)

      I feel afraid when I have to talk in front of the class (required)

      My heart suddenly starts to beat to quickly for no reason (required)

      I feel like I don’t want to move (required)

      I worry that I will suddenly get a scared feeling when there is nothing to be afraid off (required)

      I have to do some things over and over again (like washing hands, cleaning, or putting things in certain orders) (required)

      I feel afraid that I will make a fool of myself in front of other people (required)

      I have to do some things just the right way to stop bad things from happening (required)

      I worry when I am in bed at night (required)

      I would feel scared if I had to stay away from home overnight (required)

      I feel restless (required)

      Parents and Carers - RCADS questionnaire

      Please complete both questionnaires below, answering all the questions in order to progress your referral

      Please select the word that shows how often each of these things happens to your child. There are no right or wrong answers.

        Parent / Carer Name: (required)

        Child/ Young Person’s Name: (required)

        Child / Young Person's Date of Birth: (required)

        Relationship to Child / Young Person: (required)

        Date (required)

        My child worries about things (required)

        My child feels sad or empty (required)

        When my child has a problem, he/she gets a funny feeling in his/her stomach (required)

        My child worries when he/she thinks he/she has done poorly at something (required)

        My child feels afraid of being alone at home (required)

        Nothing is much fun for my child anymore (required)

        My child feels scared when taking a test (required)

        My child worries when he/she thinks someone is angry with him/her (required)

        My child worries about being away from me (required)

        My child is bothered by bad or silly thoughts or pictures in his/her mind (required)

        My child has trouble sleeping (required)

        My child worries about doing badly at school work (required)

        My child worries that something awful will happen to someone in the family (required)

        My child suddenly feels as if he/she can’t breathe when there is no reason for this (required)

        My child has problems with his/her appetite (required)

        My child has to keep checking that he/she has done things right (like the switch is off, or the door is locked) (required)

        My child feels scared to sleep on his/her own (required)

        My child has trouble going to school in the mornings because of feeling nervous or afraid (required)

        My child has no energy for things (required)

        My child worries about looking foolish (required)

        My child is tired a lot (required)

        My child worries that bad things will happen to him/her (required)

        My child can’t seem to get bad or silly thoughts out of his/her head (required)

        When my child has a problem, his/her heart beats really fast (required)

        My child cannot think clearly (required)

        My child suddenly starts to tremble or shake when there is no reason for this (required)

        My child worries that something bad will happen to him/her (required)

        When my child has a problem, he/she feels shaky (required)

        My child feels worthless (required)

        My child worries about making mistakes (required)

        My child has to think of special thoughts (like numbers or words) to stop bad things from happening (required)

        My child worries what other people think of him/her (required)

        My child is afraid of being in crowded places (like shopping centers, the movies, buses, busy playgrounds) (required)

        All of a sudden my child will feel really scared for no reasons at all (required)

        My child worries about what is going to happen (required)

        My child will become dizzy or faint when there is no reason for this (required)

        My child frequently thinks about death (required)

        My child feels afraid when they have to talk in front of the class (required)

        My child’s heart suddenly starts to beat too quickly (required)

        My child feels like he/she doesn't want to move (required)

        My child worries that he/she will suddenly get a scared feeling when there is nothing to be afraid off (required)

        My child has to do some things over and over again (like washing hands, cleaning, or putting things in certain orders) (required)

        My child feels afraid that he/she will make a fool of him/herself in front of people (required)

        My child has to do some things in just the right way to stop bad things from happening (required)

        My child worries when in bed at night (required)

        My child would feel scared if he/she had to stay away from home overnight (required)

        My child feels restless (required)