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SELF REFERRAL
Full Name
*
Date of Birth
*
/
Month
/
Day
Year
Club
*
Mobile Number
*
Email Address
*
Reason for contacting the service
Over the last 2 weeks, how often have you been bothered by any of the following problems?
Little interest or pleasure in doing things :
*
Please Select...
Not at all
Several days
More than half the days
Nearly every day
Feeling down, depressed or hopeless
*
Please Select...
Not at all
Several days
More than half the days
Nearly every day
Trouble falling or staying asleep or sleeping too much
*
Please Select...
Not at all
Several days
More than half the days
Nearly every day
Feeling tired or having little energy
*
Please Select...
Not at all
Several days
More than half the days
Nearly every day
Poor appetite or over eating
*
Please Select...
Not at all
Several days
More than half the days
Nearly every day
Feeling bad about yourself or that you are a failure or have let yourself or your family down
*
Please Select...
Not at all
Several days
More than half the days
Nearly every day
Trouble concentrating on things such as reading the newspaper or watching television
*
Please Select...
Not at all
Several days
More than half the days
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
*
Please Select...
Not at all
Several days
More than half the days
Nearly every day
Thoughts that you would be better off dead or hurting yourself in some way
*
Please Select...
Not at all
Several days
More than half the days
Nearly every day
Feeling nervous, anxious or on edge
*
Please Select...
Not at all
Several days
More than half the days
Nearly every day
Not being able to stop or control worrying
*
Please Select...
Not at all
Several days
More than half the days
Nearly every day
Worrying too much about different things
*
Please Select...
Not at all
Several days
More than half the days
Nearly every day
Trouble relaxing
*
Please Select...
Not at all
Several days
More than half the days
Nearly every day
Being so restless that it is hard to sit still
*
Please Select...
Not at all
Several days
More than half the days
Nearly every day
Becoming easily annoyed or irritable
*
Please Select...
Not at all
Several days
More than half the days
Nearly every day
Feeling afraid as if something awful might happen
*
Please Select...
Not at all
Several days
More than half the days
Nearly every day
Type a question
*
I confirm that I have read the PFAS privacy policy and understand how my personal information will be stored and processed.
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The Union
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FIFPRO
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Legal
Membership
Personal Development
Wellbeing
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Become a Business Partner
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Awards Dinner
Careers Day
Kick Off
My Future Now
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Tik Tok
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