· Osteoporosis 8% Schizophrenia 3% ... flipchart in the group. We will try and keep this to a minimum. Is reading or writing something you would require support with?

•

•

•

•

3%

8%

25%

Asthma 8%

Bipolar Disorder 1.5%

Depression 30%

Diabetes 11%

Epilepsy 3%

Heart problems 1.5%

Multiple Sclerosis 1.5%

Osteoporosis 8%

Schizophrenia 3%

Spina Bifida 1.5%

Visual Impairment 6%

55%

4%

Hot stone massage 25%

Reiki 10%

Indian head massage 6%

Figure 3: Gender of participants

83% Women

17% Men

Figure 4: Age of participants

7% 80-84

12% 75-80

20% 66-74

23% 55-65

22% 45-54

12% 35-441% 26-34

3% 85+

Figure 5: Ethnicity of participants

Indian 3%

Chinese 10%

Irish 1%

White Scottish

67%Mixed b/ground

1%

Pakistani 17%

English 1%

Figure 6: Religion of participants

Muslim 16%

Other 4%

Buddhist 1%

Christian 54%

Sikh 1%

No religion 23%

Hindu 1%

Figure 7: Percentage of participants with a

disability

No disability

24%

Disability 76%

.

•

•

Calm Project

Assessment form

It can be hard to share information about yourself with people

that you don’t know. The information that we ask you for on

this form is to help us to find out if this service is right for you

and, if it is, to find the most appropriate therapy for you.

The information you give us will not be shared (without your

permission) with anyone outside Calm unless there is a risk to

yourself or someone else involved. We may wish to share

information to access other supports for you, instead of or in

addition to complementary therapies or mindfulness. If that

situation occurs, we will discuss this with you.

Name

What do you like to be

called?

Address

Telephone

Date of birth

How did you hear about the

Calm Project?

Complementary therapies are therapies that work alongside

conventional medicine. They usually adopt a holistic approach

whereby the whole person is treated rather than just the

symptoms of an illness.

The Calm Project offers a range of complementary therapies

including Indian head massage, reflexology, massage, hot stone

massage and Reiki. Would you like further information about

what these are? (information sheets available)

Are you interested in receiving complementary therapies?

Yes No

What complementary therapies have you received in the past?

___________________________________________________

___________________________________________________

___________________________________________________

___________________________________________________

If so, can you tell us about this? (eg. what was helpful? What

was not helpful?)_____________________________________

___________________________________________________

___________________________________________________

___________________________________________________

___________________________________________________

What change would you like to experience as a result of

receiving complementary therapies?______________________

___________________________________________________

___________________________________________________

___________________________________________________

___________________________________________________

If you receive complementary therapies, would you prefer to

receive them at home or in another community setting?______

__________________________________________________

__________________________________________________

Can you tell us about this? (eg mobility problems, want to be

out of house)_______________________________________

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

You cannot have some complementary therapies if you have

particular health problems. We will talk about this further if you

are going to receive complementary therapies through the

project.

Mindfulness teaches greater awareness of thoughts and feelings

through simple techniques like meditation and gentle

movement. It also helps you develop ways of thinking and

living that can improve well-being.

Would you like further information about mindfulness?

(information sheet available)

Are you interested in attending a mindfulness group?

Yes No

Have you used mindfulness techniques in the past?

Yes No

If so, can you tell us about this? (eg. what was helpful? What

was not helpful?)___________________________________

_________________________________________________

_________________________________________________

_________________________________________________

What change would you like to experience as a result of

attending a mindfulness group?________________________

_________________________________________________

_________________________________________________

_________________________________________________

_________________________________________________

If you attend a mindfulness group, do you have any preference

about whether the group includes men and women, or women

only or men only?

Yes No

If yes, can you tell us about this?_______________________

_________________________________________________

_________________________________________________

_________________________________________________

_________________________________________________

If you attend a mindfulness group, would you require any

assistance with travel to and from the venue? Yes No

If yes, can you tell us about this? (eg. mobility problems)____

__________________________________________________

__________________________________________________

__________________________________________________

The mindfulness group may involve reading some simple

written information, either in handouts or on powerpoint or

flipchart in the group. We will try and keep this to a minimum.

Is reading or writing something you would require support with?

Yes No

If yes, what kind of support would be helpful?_____________

__________________________________________________

__________________________________________________

__________________________________________________

The group will run for 2 hours each week for 12 weeks. We’re

aware that this is a big commitment to make. Do you think you

would be able to attend regularly/have any concerns about being

able to attend regularly?_______________________________

__________________________________________________

__________________________________________________

__________________________________________________

If you participate in the mindfulness group, you will be offered

the opportunity to come back for a follow up session at a later

point. Is that something you would be interested in participating

in?

Yes No

Would you consider attending for a full day session for the

follow up?

Yes No

Can you tell us about any time constraints that may affect you

ability to participate in a follow up day? (eg. caring

responsibilities)_____________________________________

__________________________________________________

__________________________________________________

Risk Assessment

Can you tell me a bit about any mental health difficulties you

experience?

What things do you do on a regular basis to help you stay well

(in relation to both your physical and mental wellbeing)?

What helps you when you feel like this? What can a member of

staff or therapist do?

Are there any areas of safety/risk we should know about? (eg.

have you ever harmed or threatened to harm yourself or anyone

else, is there anything about the local area that we should know

about?)

If yes, can you tell me a bit about it?

Do you have any criminal convictions or have you ever had any

incidents involving the police that you think we should know

about?


If you aren’t feeling good or are becoming unwell how do you

know? How would we know?

Is drug or alcohol use a problem for you, or has it been in the

past?


Is there anything else about yourself that you think we should

know in order for us to support you appropriately?

Emergency Contact details

Please provide us with the names and addresses of two people

that we can contact in case of any emergency? One of these

contacts should be your GP.

Name (GP)

Address

Telephone

Name

Address

Telephone

Relationship to

you

GAMH Equal Opportunities Monitoring form

If you have difficulty reading or understanding this form please contact one of the staff at the Calm Project.

You are asked to complete this form for the purposes of

monitoring so that we can ensure our services are accessible

to everyone. The information you provide on this form

will be treated as strictly confidential. We do not ask for

your name.

None of the questions are compulsory, you may answer as

many or as few as you choose.

1. Your gender (please tick one box for each question)

Male

Female

Other

Have you ever considered yourself to be transgender?

Yes No

I prefer not to answer this question

2. Your age (please tick one box)

12 - 15

16 - 25

26 - 34

35 - 44

45 - 54

55 - 65

66 – 74

75 – 80

80 – 84

85+


Confidential

3. Your ethnic background The options are listed in alphabetical order, please tick one main category and if you wish one subcategory. Please note these categories are based on the Scottish census categories.

Please tick

African, Caribbean or Black; African, Caribbean or Black Scottish; any other African, Caribbean or Black British or Black Irish

African (please specify), African Scottish, any other African British or African Irish

Caribbean, Caribbean Scottish, any other Caribbean British or Caribbean Irish

Any other African, Caribbean or Black background (please specify)

Please tick

Asian, Asian Scottish, any other Asian British or Asian Irish

Bangladeshi, Bangladeshi Scottish, Bangladeshi Irish, any other Bangladeshi British

Indian, Indian Scottish, Indian Irish or any other Indian British

Pakistani, Pakistani Scottish, Pakistani Irish or any other Pakistani British

Any other Asian background (please specify)

Please tick

Chinese, Chinese Scottish, Chinese Irish, Chinese British

Any other Chinese background (please specify)

Confidential Please tick

Gypsy/Traveller

Irish Traveller

New Traveller

Roma

Scottish Gypsy/Traveller

Showperson

Any other Gypsy/Traveller background (please specify)

Please tick

White

British

English

Irish

Northern Irish

Scottish

Welsh

Polish

Any other white background (please specify)

Please tick

Mixed or multiple background

Any mixed or multiple background (please specify)

Please tick

Other ethnic background

Any other background (please specify)


Confidential

4. Your current religion or belief

No religion

Bahai

Buddhist

Christian

Hindu

Humanist

Jain

Jewish

Muslim

Pagan

Sikh

Other


5. Your sexual orientation

Bisexual

Gay man/ homosexual

Lesbian / Gay woman

Heterosexual / straight

Other


6. Caring Responsibilities: Are you responsible for caring for a family member or other person?

Yes

No


Confidential 7. Disability

Definition of Disability The Disability Act 1995 & 2005 protects disabled people. It defines a person as disabled if they ‘have a physical or mental impairment, which has a substantial and long term (i.e. has lasted, or is expected to last at least 12 months) and has an adverse effect on the person’s ability to carry out day to day activities.’ Do you consider yourself to have a disability according to the definition given in the Disability Discrimination Act described above?

Yes

No

Please state the type of impairment which applies to you. People may experience more than one type of disability or impairment, in which case please tick more than one box.

Physical disability or impairment

Visual disability or impairment, such as serious visual impairment, being blind.

Deafened, deaf, hard of hearing

Deaf BSL

Mental Health problem, such as depression

Learning disability or difficulty such as dyslexia, autism, Down’s syndrome; or head injury

Long-standing illness or health condition, such as cancer, HIV, diabetes, chronic heart disease or epilepsy

Other disability or impairment, such as disfigurement (please specify)


Confidential 8. Immigration status Asylum seeker

Yes

No

Refugee

Yes

No


Thank you for taking the time to complete this information. It is helpful to us in making our service accessible to everyone.

Calm Project

Review Form

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Documents

· Osteoporosis 8% Schizophrenia 3% ... flipchart in the group. We will try and keep this to a minimum. Is reading or writing something you would require support with?