Get help for low mood or anxiety

Patient Warning

This is not an emergency form. If you require immediate help or are considering self harm, you can seek help and advice today by visiting 111.nhs.uk or calling 111 and selecting option 2.

Use this form at any time to get help from your practice. We aim to respond within 2 working hours.

Get help for low mood or anxiety

About the Patient's Problem

If you're not sure, it's helpful to tell us whether it's been days, weeks, months or years.

Over the last 2 weeks, how often have you been bothered by any of the following problems:

Little interest or pleasure in doing things: *
Feeling down, depressed, or hopeless: *
Trouble falling or staying asleep, or sleeping too much: *
Feeling tired or having little energy: *
Poor appetite or overeating: *
Feeling bad about yourself — or that you are a failure or have let yourself or your family down: *
Trouble concentrating on things, such as reading the newspaper or watching television: *
Moving or speaking so slowly that other people could have noticed? Or the opposite — being so fidgety or restless that you have been moving around a lot more than usual: *
Thoughts that you would be better off dead or of hurting yourself in some way: *
Have you made any plans to end your life soon? *

For immediate help

This is not an emergency form. If you require immediate help or are considering self harm, you can seek help and advice today by visiting 111.nhs.uk or calling 111 and selecting option 2.

Do you suffer from anxiety? *

Over the last 2 weeks, how often have you been bothered by the following problems?

Feeling nervous, anxious, or on edge *
Not being able to stop or control worrying *
Worrying too much about different things *
Trouble relaxing *
Being so restless that it's hard to sit still *
Becoming easily annoyed or irritable *
Feeling afraid as if something awful might happen *

People often use alcohol in an attempt to manage feelings of anxiety and depression. However, alcohol often makes mental health problems worse.

Do you drink alcohol?

This is one unit of alcohol:

Amount of different types of drink representing one unit of alcohol

And each one of these, is more than one unit:

Amount of different types of drink representing more than one unit of alcoholAmount of different types of drink representing more than one unit of alcohol
How often do you have a drink containing alcohol? *
How many units of alcohol do you drink on a typical day when you are drinking? *
How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year? *
How often during the last year have you found that you were not able to stop drinking once you had started? *
How often during the last year have you failed to do what was normally expected from you because of your drinking? *
How often during the last year have you needed an alcoholic drink in the morning to get yourself going after a heavy drinking session? *
How often during the last year have you had a feeling of guilt or remorse after drinking? *
How often during the last year have you been unable to remember what happened the night before because you had been drinking? *
Have you or somebody else been injured as a result of your drinking? *
Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested that you cut down? *

Smoking can relieve feelings of anxiety for a few minutes. However, smoking actually increases anxiety. Stopping smoking is proven to improve mood and help relieve stress, anxiety and depression.

Do you smoke?

If you currently smoke

How many cigarettes do you smoke in a day?
Would you like to give up smoking?

Please contact SmokeFree Norfolk for help quitting (Opens in new tab)

If you do not currently smoke

Have you smoked in the past?
How many cigarettes did you smoke in a day?

Physical Activity

Physical activity raises your self-esteem and causes chemical changes in your brain which improve your mood.

File Upload

Please send photos if you think a photo would help our clinicians.
Drop a file here or click to upload Choose File
Maximum upload size: 67.11MB

Communication Preferences

How would you like us to deal with the problem? *
Video Consultation

Video consultations require you to have a smartphone, tablet, laptop or any computer with camera and microphone or headset. You will also require access to the internet, preferably over WiFi. If the practice decides on a video consultation you will be sent an email containing a link for the video consultation, so it's best if you can receive your emails on that same device.

How quickly do you think the problem needs to be dealt with? *

If the practice has a mobile number for you, we may send text messages to this number to inform you of an appointment time, or to allow you to book an appointment at a time of your choice.

Terms & Conditions *