Initial Assessment | Beyond Reflections

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Assessment form

Date of birth*

Preferred name*

Pronouns (optional)

They/Them

She/her

He/him

She/they

He/they

She/He/They

Other

I am...

Discord contact (optional)

Legal name*

Today's date

Current goals - short term (6-12 months)* (optional)

Current goals - long term (12month+) (optional)

If applicable: which mental health conditions have you been professionally diagnosed with? (optional)

If applicable: which mental health conditions do you suspect you have, or have self-diagnosed? (optional)

If applicable, please name any substances that you regularly use/misuse, such as illicit drugs or alcohol. Please also include any historical substance issues and the year and month that you last used the substance listed. (optional)

Please tell us if you have any triggers, what happens when you are triggered, and how you manage this, or leave blank if none (optional)

If applicable: please give more information about your neurodivergence if you have selected learning difficulties, learning disability, or other neurodivergence (optional)

Health conditions (optional)

Physical disability (optional)

Please let us know of any support or access needs that you have (optional)

Have you experienced any hate crime?

Criminal convictions (optional)

Have you used our services in the past?

How did you hear about us?

How did you hear about us additional information (optional)

Which of the following are supportive of you? (select all that apply)

family

friends

partner(s)

other

none of the above

has your mental health been impacted by your/their transition

Has your employment status been impacted by your/their transition

Has your housing status been impacted by your/their transition

Have any of your relationships been impacted by your/their transition?

Are there any other things that you think that we should know about you or your current circumstances? (optional)

Beyond Reflections is a low cost service run with a membership structure. Most members pay towards support received.

Declarations

I am an adult (18+ years old) and living in England or Wales

I confirm that the above information is true to the best of my knowledge, and I have left out nothing asked for above

I understand that the next step in the onboarding process is a video call in which I will need to show photo identification

I have read and accept the membership agreement

Membership agreement

I have read and accept the privacy policy

I have read and accept the 1-1 support agreement

1-1 support agreement

I have read and accept the counselling agreement

Counselling agreement

I have read and accept the in-person group agreement

In-person group agreement

I have read and accept the in-person social spaces agreement

In person social spaces agreement

I have read and accept the online group agreement

Group agreement

I have read and accept the online social spaces agreement

Online social spaces agreement

I have read and accept the supported outing agreement

Supported outing agreement

I understand that this will be considered my digital signature for the purposes of this form

If you are a human, ignore this field

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