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TELEPHONE SUPPORT HELPLINE
ASSESSMENT FORM

Please confirm if you are experiencing any of the following;
Risk Level:

GENERAL MENTAL HEALTH ASSESSMENT

Level A
Level B
Level C
Can you confirm if you are experiencing, or have been formally assessed or diagnosed with any of the following;
RISK ASSESSMENT

WORK RELATED ASSESSMENT

On a scale of 1-5 (1 being not at all and 5 being all the time) can you confirm if these issues have prevented you from concentrating on your work?

RECOMMENDATION GIVEN

Form submitted & Email copy sent to info@therapycentreservices.com

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