Registration

Personal Details

Name *

First

Last

Email *

Date of Birth

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Primary Contact Number *

Secondary Contact Details eg Mobile Phone

Next of Kin/ Emergency Contact Name *

First

Last

Next of Kin/ emergency contact number

GP Name *

First

Last

GP Contact Number

Do you consent to us leaving voicemail messages? *

Do you consent to us corresponding with you using the email address provided *

Employment Details

Employer Code (where applicable)

Employer Name *

Your Current job Title *

	Not at all	Slightly	Definitely	Markedly	Severely
Mental wellbeing (eg. Stress, mood, anxiety, Optimism, helplessness etc)	Mental wellbeing (eg. Stress, mood, anxiety, Optimism, helplessness etc) Not at all	Mental wellbeing (eg. Stress, mood, anxiety, Optimism, helplessness etc) Slightly	Mental wellbeing (eg. Stress, mood, anxiety, Optimism, helplessness etc) Definitely	Mental wellbeing (eg. Stress, mood, anxiety, Optimism, helplessness etc) Markedly	Mental wellbeing (eg. Stress, mood, anxiety, Optimism, helplessness etc) Severely
Work (eg, motivation, concentration, attendance, meeting deadlines etc)	Work (eg, motivation, concentration, attendance, meeting deadlines etc) Not at all	Work (eg, motivation, concentration, attendance, meeting deadlines etc) Slightly	Work (eg, motivation, concentration, attendance, meeting deadlines etc) Definitely	Work (eg, motivation, concentration, attendance, meeting deadlines etc) Markedly	Work (eg, motivation, concentration, attendance, meeting deadlines etc) Severely
Private leisure activities (doing things alone such as reading, walking, hobbies etc)	Private leisure activities (doing things alone such as reading, walking, hobbies etc) Not at all	Private leisure activities (doing things alone such as reading, walking, hobbies etc) Slightly	Private leisure activities (doing things alone such as reading, walking, hobbies etc) Definitely	Private leisure activities (doing things alone such as reading, walking, hobbies etc) Markedly	Private leisure activities (doing things alone such as reading, walking, hobbies etc) Severely
Relattionships (forming and maintaining close relationships including with those who you live with)	Relattionships (forming and maintaining close relationships including with those who you live with) Not at all	Relattionships (forming and maintaining close relationships including with those who you live with) Slightly	Relattionships (forming and maintaining close relationships including with those who you live with) Definitely	Relattionships (forming and maintaining close relationships including with those who you live with) Markedly	Relattionships (forming and maintaining close relationships including with those who you live with) Severely

Availability

Please specify when you would be available to attend a one to one session. Our opening hours are 8am - 9pm every day. (please check all that apply)

Confidentiality

Confidentiality AzuraMinds takes confidentiality and data protection extremely seriously and we manage, store and use your personal data for the purposes of your treatment only. We ensure complete confidentiality throughout any contact with AzuraMinds, whilst responding appropriately to any situation where there is a risk of harm to self or others, as we are legally required. Data Protection By signing this form I consent to relevant information about my condition and treatment being shared between a multi-disciplinary team of health professionals at AzuraMinds involved in my care. Once form is completed Thank you for contacting us. We will be in touch within the next 1-2 days to arrange your AzuraMOT.

Data Protection

By signing this form I confirm that I understand that a multi-disciplinary team of health professionals at AzuraMinds may be involved in my care and will share relevant information about my condition and treatment.

Signature *

Thank You for completing our registration form. We will contact you within 3-5 working days to arrange your first appointment

	Not at all	Several Days	More than half the days	Nearly every Day
Feeling nervous, anxious or on edge	Feeling nervous, anxious or on edge Not at all	Feeling nervous, anxious or on edge Several Days	Feeling nervous, anxious or on edge More than half the days	Feeling nervous, anxious or on edge Nearly every Day
Being unable to control or stop worrying	Being unable to control or stop worrying Not at all	Being unable to control or stop worrying Several Days	Being unable to control or stop worrying More than half the days	Being unable to control or stop worrying Nearly every Day
Worrying too much about different things	Worrying too much about different things Not at all	Worrying too much about different things Several Days	Worrying too much about different things More than half the days	Worrying too much about different things Nearly every Day
Trouble Relaxing	Trouble Relaxing Not at all	Trouble Relaxing Several Days	Trouble Relaxing More than half the days	Trouble Relaxing Nearly every Day
Being so restless that it is hard to sit still	Being so restless that it is hard to sit still Not at all	Being so restless that it is hard to sit still Several Days	Being so restless that it is hard to sit still More than half the days	Being so restless that it is hard to sit still Nearly every Day
Becoming easily annoyed or irritable	Becoming easily annoyed or irritable Not at all	Becoming easily annoyed or irritable Several Days	Becoming easily annoyed or irritable More than half the days	Becoming easily annoyed or irritable Nearly every Day
Feeling afraid as if something awful might happen	Feeling afraid as if something awful might happen Not at all	Feeling afraid as if something awful might happen Several Days	Feeling afraid as if something awful might happen More than half the days	Feeling afraid as if something awful might happen Nearly every Day
Having little interest or pleasure in doing things	Having little interest or pleasure in doing things Not at all	Having little interest or pleasure in doing things Several Days	Having little interest or pleasure in doing things More than half the days	Having little interest or pleasure in doing things Nearly every Day
Feeling down, depressed or hopeless	Feeling down, depressed or hopeless Not at all	Feeling down, depressed or hopeless Several Days	Feeling down, depressed or hopeless More than half the days	Feeling down, depressed or hopeless Nearly every Day
Trouble falling or staying asleep	Trouble falling or staying asleep Not at all	Trouble falling or staying asleep Several Days	Trouble falling or staying asleep More than half the days	Trouble falling or staying asleep Nearly every Day
Feeling tired or having little energy	Feeling tired or having little energy Not at all	Feeling tired or having little energy Several Days	Feeling tired or having little energy More than half the days	Feeling tired or having little energy Nearly every Day
Poor appetite or overeating	Poor appetite or overeating Not at all	Poor appetite or overeating Several Days	Poor appetite or overeating More than half the days	Poor appetite or overeating Nearly every Day
Feeling bad about yourself - or that you are a failure, or have let yourself or your family down	Feeling bad about yourself - or that you are a failure, or have let yourself or your family down Not at all	Feeling bad about yourself - or that you are a failure, or have let yourself or your family down Several Days	Feeling bad about yourself - or that you are a failure, or have let yourself or your family down More than half the days	Feeling bad about yourself - or that you are a failure, or have let yourself or your family down Nearly every Day
Trouble concentrating on things, such as reading the newspaper or watching television	Trouble concentrating on things, such as reading the newspaper or watching television Not at all	Trouble concentrating on things, such as reading the newspaper or watching television Several Days	Trouble concentrating on things, such as reading the newspaper or watching television More than half the days	Trouble concentrating on things, such as reading the newspaper or watching television Nearly every Day
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	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	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 Several Days	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 More than half the days	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 Nearly every Day
Thoughts that you would be better off dead or having thoughts of hurting yourself in some way	Thoughts that you would be better off dead or having thoughts of hurting yourself in some way Not at all	Thoughts that you would be better off dead or having thoughts of hurting yourself in some way Several Days	Thoughts that you would be better off dead or having thoughts of hurting yourself in some way More than half the days	Thoughts that you would be better off dead or having thoughts of hurting yourself in some way Nearly every Day

Personal Details

Employment Details

Current Health and Wellbeing

Availability

Confidentiality

Data Protection