Maternal Pituitary Support Therapeutic Session Application
Please fully complete this form to apply for a place on our National Lottery Funded project.
GP (please provide name of practice and address) *
- {name}
I consent for you to store my data in line with our privacy policy (https://static1.squarespace.com/static/615ec1175334524d9e899450/t/62a1b504d4f0c103950d852a/1654764806167/2022-05-27_PRO_3_Privacy+Policy.pdf) *
I consent for you to share this application form with our GDPR compliant third party provider, The Self Space *
Are you under the care of community mental health services? Disclaimer: please note that our provider (Self Space) are unable to treat you whilst you are under the care of community mental health services. *
- Yes
- No
What type of Maternal Pituitary Condition do you have? *
You can find out more information about Acute and Chronic presentation here: https://maternalpituitarysupport.org/sheehans-syndrome-explained
- Acute Sheehan's Syndrome
- Chronic Sheehan's Syndrome
- Lymphocytic Hypophysitis
- Other pituitary condition arising in pregnancy, childbirth or post-partum
Is there anything you would like to share about yourself or your journey with a maternal pituitary condition? Is there anything you are finding difficult at the moment?
- {name}
I agree to complete an evaluation form following my sessions *
Please complete the following 10 questions.
We are very grateful to Core Systems Trust for granting us permission to use the CORE-10 in this application form. CORE-10 © CORE System Trust: https://www.coresystemtrust.org.uk/copyright.pdf
Over the last week...
1. I have felt tense, anxious or nervous *
- Not at all
- Only occasionally
- Sometimes
- Often
- Most or all of the time
2. I have felt I have someone to turn to for support when needed *
- Not at all
- Only occasionally
- Sometimes
- Often
- Most or all of the time
3. I have felt able to cope when things go wrong *
- Not at all
- Only occasionally
- Sometimes
- Often
- Most or all of the time
4. Talking to people has felt too much for me *
- Not at all
- Only occasionally
- Sometimes
- Often
- Most or all of the time
5. I have felt panic or terror *
- Not at all
- Only occasionally
- Sometimes
- Often
- Most or all of the time
6. I made plans to end my life *
- Not at all
- Only occasionally
- Sometimes
- Often
- Most or all of the time
7. I have had difficulty getting to sleep or staying asleep *
- Not at all
- Only occasionally
- Sometimes
- Often
- Most or all of the time
8. I have felt despairing or hopeless *
- Not at all
- Only occasionally
- Sometimes
- Often
- Most or all of the time
9. I have felt unhappy *
- Not at all
- Only occasionally
- Sometimes
- Often
- Most or all of the time
10. Unwanted images or memories have been distressing me *
- Not at all
- Only occasionally
- Sometimes
- Often
- Most or all of the time
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