Psychological Triage

CONSENT PAGE
• Consent and How we use your data:
Innovate Healthcare Management Group Limited (“Innovate”) respects your privacy and is committed to protecting your personal data. This privacy notice will inform you as to how we look after your personal data when you utilise our Triage Service, and tell you about your privacy rights and how the law protects you. The result of this assessment will be shared with Wesleyan on an anonymous basis for Management Information purposes.
• Who we are:
We are, Innovate Healthcare Management Group Limited and our office is based at Dale House, Tiviot Dale, Stockport, SK1 1TA. We are a registered company in England and Wales under company number 07758732. We are registered on the Information Commissioner’s Office Register; registration number Z3289411. We act as a data controller while processing your information, for further information, or to exercise any of your rights under the Data Protection Act 2018, please contact our Data Protection Officer at [email protected] or at the postal address above.
• During this assessment, we will collect the following information from you:
Personal Information including: name, contact information. Special Category information: Health data
• How we will use your data:
Following the online assessment, your data may be reviewed by a qualified CBT Practitioner, and an appropriate support pathway recommended.
I hereby consent to the Triage Assessment and any subsequent support interventions recommended by Innovate Healthcare.*
- I hereby consent to the Triage Assessment and any subsequent support interventions recommended by Innovate Healthcare.
I agree to my data being held and processed by Innovate Healthcare for the purpose of this service provision. Should I require further support interventions, I consent for Innovate Healthcare to share my details and a summary of the information provided with my referring party for the purposes of seeking authorisation (post Triage Assessment).*
- I agree to my data being held and processed by Innovate Healthcare for the purpose of this service provision. Should I require further support interventions, I consent for Innovate Healthcare to share my details and a summary of the information provided with my referring party for the purposes of seeking authorisation (post Triage Assessment).
I understand that the clearer I can be regarding the specific event/situation/incident which led to my referral, in addition to what I would like to work on now in therapy, will lead to quicker allocation to the most suitable therapist and therapy approach’.*
- I understand that the clearer I can be regarding the specific event/situation/incident which led to my referral, in addition to what I would like to work on now in therapy, will lead to quicker allocation to the most suitable therapist and therapy approach.

Innovate Healthcare Reference:
Referrer Name:
Referrer Surname:
Referrer reference:
Referrer email address:
First Name:*
Surname:*
Email Address:*
Date of birth:*

We do not pass on any of your answers to your GP. We keep GP details only whilst your referral is active with us, in case of risk/emergency.
GP name:*
Surgery name:*
Surgery address:*
City ZIP / Postal Code
Surgery phone number:*

Are you currently taking any medication for your mental health e.g. anti-depressants; anti-anxiety medication?*
- No
- Yes
If known, what is the name of the medication and the dosage?

Do you use recreational drugs?*
- No
- Yes
Please provide further information:*
How many units of alcohol do you drink per week?*
Click here to view the unit calculator

Have you ever had a diagnosis from a Psychologist, Psychiatrist, or Mental Health Nurse for a severe/complex mental health condition?*
- No
- Yes
If Yes what was diagnosed, and approx. when?*
Have you ever experienced any common mental health issues such as Anxiety and/or Depression*
- No
- Yes
If Yes please comment:*

Have you had any therapy before?*
- No
- Yes
Which form of therapy did you have:*
- CBT
- Counselling/Psychotherapy
- EMDR
- Other
- I don’t know
Please specify:*
If Yes to the above what did you find helpful/unhelpful regarding your past experience of therapy?*

What is the main issue that is causing you the most distress at present, that you would like to prioritise working on now?*
How long have you been feeling distressed about this particular issue which you would now like to prioritise working on now?*
What do you hope to achieve in Psychological therapy sessions now?*
Would you be able to commit to regular (weekly) video therapy sessions?*

Step 1 of 11

CONSENT PAGE

We do not pass on any of your answers to your GP. We keep GP details only whilst your referral is active with us, in case of risk/emergency.

Anxiety – GAD 7

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

Anxiety – GAD 7: @{Anxiety – GAD 7::117}

Low mood/Depression – PHQ9

Innovate does not operate a service for mental health emergencies. In an emergency, please contact your GP, NHS Choices on 111, the Samaritans on 116 123, or the Accident and Emergency Department of your local Hospital or NHS Trust.

Low mood/Depression – PHQ9: @{Low mood/Depression – PHQ9::121}

Impact of Events Scale – Revised

Below is a list of difficulties people sometimes have after a stressful life event. Please read each item, and then indicate how distressing each difficulty has been for you DURING THE PAST SEVEN DAYS with respect to (the event). How much were you distressed or bothered by these difficulties?

If you are rating the below questions, please give a brief summary of the ONE MAIN overwhelming event/incident on which you are basing your scores.

Impact of Events Scale – Revised: @{Impact of Events Scale – Revised::141}