Private and Confidential when completed
Confidential Impact and Effectiveness Questionnaire
Over the last 6 weeks, how often have you:
In the last 6 months:
If you responded 'Yes' to any of the above, how much of a problem did this cause you? EG being unable to work, losing close family links, money or legal troubles.
If not signed, registration cannot be processed.
I understand by printing my name on the signature line provided, this counts as my signature
Please note that all data is treated with the strictest confidentiallity and will be held in accordance to the Data Protection Act.
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