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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.
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
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
2. I have felt I have someone to turn to for support when needed
3. I have felt able to cope when things go wrong
4. Talking to people has felt too much for me
5. I have felt panic or terror
6. I made plans to end my life
7. I have had difficulty getting to sleep or staying asleep
8. I have felt despairing or hopeless
9. I have felt unhappy
10. Unwanted images or memories have been distressing me

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