Applied Clinical Psychology Services Ltd tSarah (Secretary) 07543 993 519 esarahwigg@acpsltd.co.uk wwww.acpsltd.co.uk Pre-Interview Questionnaire 1General Information2BEFORE the Incident / Accident34The Incident / Accident General InformationName(Required) First Last Marital Status(Required)SingleMarriedCo-habitingSeparatedDivorcedDo you have children?(Required) Yes No Ages of children:(Required) Add RemoveDate of Incident(Required) DD slash MM slash YYYY Are you employed? Yes No State job title / part time or full time / No. of hours worked BEFORE the Incident / AccidentThese questions relate to your life at any time before the incident / accident. This helps us to gather background information which is essential for our report.Do you have any previous or pending criminal convictions?(Required) Yes No Have you ever had any previous problems with drugs or alcohol?(Required) Yes No Have you ever had any previous personal injury claims?(Required) Yes No As you have answered YES to one of the above, please give details below:Have you ever had any significant incidents, accidents or traumas at any time before this incident / accident?(Required) Yes No Please give brief details below (e.g. approximate year, what type of trauma or incident, any significant injuries, any psychological or emotional problems afterwards):(Required)Have you ever seen your GP before the incident / accident for any psychological difficulties such as anxiety, depression, low mood or stress at any time in your life?(Required) Yes No Please give brief details below:(Required) Before the incident / accident had you ever been prescribed antidepressants, sedatives or sleeping tablets?(Required) Yes No Were you taking any of the above medication at the time of the incident / accident?(Required) Yes No Before the incident / accident had you ever seen a psychologist, therapist, counsellor or any other mental health professional?(Required) Yes No In the 12 months before the incident / accident, did any stressful events or problems occur in your life?(Required) Yes No As you have answered YES to one of the above, please give details below:In your opinion, immediately before the incident / accident, did you have any psychological difficulties, e.g. anxiety, depression, stress or mood variability?(Required) Yes No Please give details below: THE INCIDENT / ACCIDENTThese questions relate to the incident / accident. Not all the questions may be relevant to your incident / accident. Please answer all that are relevant, as best you can.Please briefly describe what happened in the incident / accident:Describe what you thought and felt when the incident / accident happened:
