10. Mental health Does the applicant have a history of mental health issues? YES NO If please provide the following information (if please turn to next page):- ‘YES’ ‘NO’ Nature of mental health issues (please give formal diagnosis if one exists) Please indicate the level of the applicant’s insight regarding their mental health Have there been any psychiatric admissions in YES NO the past 3 years? If please provide details:- ‘YES’ Does the applicant have a history of self-harm/suicide? YES NO If please provide details:- ‘YES’ What are the likely triggers which may lead the applicant to suffer a mental health relapse? What symptoms does the applicant display when unwell? Please list any medication currently taken Is the applicant reliable in self-medicating? N/A YES NO If the applicant receives support for mental health issues, please give details of support provider below: Name: Agency: 11. Well-being / physical health (please tick) Does the applicant suffer from any of the following? Mobility difficulties Anger management Asthma
10. Mental health Does the applicant have a history of mental health issues? YES NO If ‘YES’ please provide the following information (if ‘NO’ please turn to next page):- Nature of mental health issues (please give formal diagnosis if one exists) Please indicate the level of the applicant’s insight regarding their mental health Have there been any psychiatric admissions in YES NO the past 3 years? If ‘YES’ please provide details:- Does the applicant have a history of self-harm/suicide? YES NO If ‘YES’ please provide details:- What are the likely triggers which may lead the applicant to suffer a mental health relapse? What symptoms does the applicant display when unwell? Please list any medication currently taken Is the applicant reliable in self-medicating? N/A YES NO If the applicant receives support for mental health issues, please give details of support provider below: Name: Agency: 11. Well-being / physical health Does the applicant suffer from any of the following? (please tick) Mobility difficulties Anger management Asthma