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Clinician to administer this section
The following questions are about your emotional wellbeing. Your answers will help me get a clearer idea of what has been happening in your life and suggest possible ways that we might work together to relieve any distress you may be experiencing. We ask these questions of everybody, and they include questions about mental, physical and emotional health.
1. Have you ever seen a doctor or psychiatrist for emotional problems or problems with your ‘nerves’/anxieties/worries?

   No   Yes



2. Have you ever been given medication for emotional problems or problems with your ‘nerves’/anxieties/worries?
No, never
Yes, in the past but not currently Medication(s):
Yes, currently Medication(s):
3. Have you ever been hospitalised for emotional problems or problems with your ‘nerves’/anxieties/worries?

   No   Yes



4. Do you have a current mental health worker, psychiatrist, psychologist, general practitioner or other health provider? If ‘No’, go to Question 5.

Psychiatrist   Psychologist
Name:   Name:
Contact details:   Contact details:
Role:   Role:
 
Mental health worker   General practitioner
Name:   Name:
Contact details:   Contact details:
Role:   Role:
   
Other - specify:   Other - specify:
Name:   Name:
Contact details:   Contact details:
Role:   Role:
5. Has the thought of ending your life ever been on your mind?
No (Go to Section 3)  
Yes  
Has that happened recently?
No   Yes  
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