Pfascotland - Self Referral Form

Full Name*

Date of Birth*

Club*

Mobile Number*

Email Address*

Reason for contacting the service

Over the last 2 weeks, how often have you been bothered by any of the following problems?

Little interest or pleasure in doing things :*

Feeling down, depressed or hopeless *

Trouble falling or staying asleep or sleeping too much*

Feeling tired or having little energy *

Poor appetite or over eating*

Feeling bad about yourself or that you are a failure or have let yourself or your family down*

Trouble concentrating on things such as reading the newspaper or watching television*

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*

Thoughts that you would be better off dead or hurting yourself in some way*

Feeling nervous, anxious or on edge*

Not being able to stop or control worrying*

Worrying too much about different things*

Trouble relaxing*

Being so restless that it is hard to sit still*

Becoming easily annoyed or irritable*

Feeling afraid as if something awful might happen*

Type a question*

I confirm that I have read the PFAS privacy policy and understand how my personal information will be stored and processed.