Please tick if you would like to meet with a worker to discuss your emotional wellbeing.

At Mind and Body, we are committed to keeping you and your data safe. We follow the law, which puts your rights at the heart of how we treat your data.

We collect information about you to provide you with the best care and support. We keep your data safely on our secure databases. We share key information with your GP to join up your care. We also send data to NHS Digital, our commissioners, who pay for the service, to show how we are performing. Other than that, we don’t share information about you without your consent unless there is a risk of harm to you or others.

If you would like further information, please see contact details at the end of the survey.

If you are identified as being eligible for support based on your survey completion, we will contact you to arrange an initial appointment.

Please leave your preferred contact details (phone number/email address) below:

(Please enter at least a minimum of two characters within the (First & Last Name)

First Name

Last Name

Phone Number

Email Address

Date of Birth

Please use format 01/01/2001

Age

I identify my gender as...

Other

Sexual orientation

Other

Ethnicity

Religion

Do any of the following apply (you can select more than one):

To select more than one value, press 'Ctrl' on your keyboard while clicking your answers.

Additional Educational Needs

To select more than one value, press 'Ctrl' on your keyboard while clicking your answers.

My Views

1. Over the past month on how many days have you felt tired or had low energy?

2. Over the past month on how many days have you felt down, depressed or hopeless?

3. Do you ever automatically think the worst in a situation?

None of the timeRarelySome of the timeOftenAll of the timeExample: If someone is late automatically thinking something bad has happened.

4. It's common for people to worry. Do you ever feel overwhelmed by your worries and concerns?

5. When I am feeling overwhelmed by worries or concerns I tend to:

Please answer each option, if it is not relevant for you please answer 'None of the time'

	None of the time	Rarely	Some of the time	Often	All of the time
5a. Spend time on my own
5b. Become angry and upset
5c. Try to not think about and forget the problem
5d. Blame myself

6. When I am feeling overwhelmed by worries or concerns I try to cope by:

Please answer each option, if it is not relevant for you please answer 'None of the time'

	None of the time	Rarely	Some of the time	Often	All of the time
6a. Taking part in hobbies, activities or exercise
6b. Using alcohol
6c. Seeking out friends for support
6d. Seeking out family for support

7. How likely are you to NOT think about the consequences before you act or make a decision?

If this survey has brought up difficult feelings for you or you feel unable to keep yourself safe then please speak to your school Safeguarding Lead or Pastoral Team.

CONTACT INFORMATION

If you require any further information, please contact your local Mind & Body service (9-5 Monday to Friday) Mind and Body is not an emergency service. If your circumstances escalate please contact your GP, local CAMHS service or present yourself to accident and emergency.

Mind & Body Kent:

Email: mabadmin@wearewithyou.org.uk

Phone: 01795 500882

Website: https://www.wearewithyou.org.uk/local-hubs/kent/services/mind-and-body

Mind & Body Cornwall:

Email: mabcornwall@wearewithyou.org.uk

Phone: 01872 300816

Website: https://www.wearewithyou.org.uk/local-hubs/cornwall/services/support-for-young-people