As part of your upcoming annual review we would be grateful if you could complete the following questionnaire. This is to provide you with an opportunity to let us know of any concerns, worries or difficulties you may have so we can provide better care and support.

Information provided in this questionnaire will be sent to the psychologists who work in the team to review before you attend your clinic appointment, and will be shared with the rest of the team as part of your overall annual review. A psychologist may be present in your annual review to discuss further. Alternatively you can request a brief call with a psychologist using the questionnaire or request in clinic.

The information you submit using this questionnaire will be kept confidential. If there any concerns around your safety based on your answers, a member of the team will be in touch by phone to discuss further when your form is reviewed.

We are not a crisis service and cannot review your questionnaire immediately. If you feel you cannot keep yourself safe please contact your GP, or if you are in Leicestershire you can call 111 and select the mental health option, or if you are in Northamptonshire you can call 0800 448 0828. Call 999 if there is an immediate risk to your life.

More information about mental health support is available on our website.