Assessment Form For AFOS- Group Consultation Assessment Form – Group Consultation To be completed by the participant without influence. Please complete the information on this form. Completing this form accurately helps 360 Psyche assess the situation effectively so we can provide the best service. It may seem long, but most of the questions require only a check, so it will go quickly. If you have any questions, please send us a WhatsApp message on 08096642604 or send an email to info@360psyche.com and we would respond ASAP. SECTION 1: PERSONAL INFORMATION User Code (Sent to your email. Please do not include your name) * How old are you * Birthday Day Gender * Marital Status SECTION 2: TRAUMA HISTORY Tell us a bit about the traumatic experience * Current Symptoms Checklist (Please check all that applies to you) * Depressed Mood Excessive Worry Impulsivity Sleep Pattern Disturbance Loss of Interest Low Motivation Decreased Libido Concentration Problems/ Forgetfulness Change in Appetite Excessive Guilt Decreased need for sleep Crying Spells Increased Risky Behaviours Unable to Enjoy Activities Anxiety/ Panic Attacks Avoidance Increased Libido Racing Thoughts Suspiciousness Excessive Energy Increased Irritability Excessive Need for Sleep Fatigue None of the above Were these symptoms present before 1st June, 2022 * Not at all Yes, just a little Yes, somewhat Yes, most of them Yes, all of them Have these symptoms increased since 1st June, 2022 * Not at all Yes, just a little Yes, somewhat Yes, most of them Yes, all of them So far, what solutions have been helpful? * Have you experienced any previous trauma (e.g. serious accident, life threatening illness, sexual abuse, etc) * Yes No Can't Remember If yes, please specify the traumatic experience Have you struggled with any of these in the past (check all that applies) * Post Traumatic Stress Disorder Depression Anxiety Alcohol Abuse Other Substance Abuse (e.g. Marijuana, Tobacco) Schizophrenia Bipolar Affective Disorder Anger Management Suicide/ Suicidal Thoughts None of the above SECTION 3: PREFERENCES Would you like us to send you follow-up emails? (We don’t spam) * Yes No Follow-up emails help check in on your general well-being and provide proven psychological tips for the traumatic experience, stress management, relationships, etc. for a healthy work-life balance and well-being If yes, when is your most preferred time of the day? Mornings Afternoons Evenings Night Time Would you like us to place follow-up calls? (We don’t spam) * Yes No Follow-up calls give you an avenue to express yourself to a trained phone helpline. We’ll notify you via email before placing a call. If yes, when is your most preferred time of the day? Mornings Afternoons Evenings Night Time Would like to have one-on-one sessions (individual) Yes No Not sure Is there anything else you’ll like us to know? If you are human, leave this field blank. Submit Δ
