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ICAN Support - Initial Information and Assessment Questionnaire
This form is for people referred to us by the ICAN Service in North Wales. ICAN Support is provided by Tan Y Maen Wellbeing Centre and through Parabl Talking Therapies. Completing this form will to enable us to get some initial information about you and the type of support you are looking for. It will help us to make an initial assessment of your suitability for the services we are able to offer. Please answer all the questions. This form is CONFIDENTIAL to ICAN Support provided by Tan Y Maen Wellbeing Centre and Parabl Talking Therapies and the information you provide will not be shared with anyone else. Most of this form can be answered in English or Welsh.
Mae'r ffurflen hon ar gyfer pobl a gyfeiriwyd atom gan Wasanaeth ICAN yng Ngogledd Cymru. Darperir Cymorth ICAN gan Ganolfan Lles Tan Y Maen a thrwy Therapïau Siarad Parabl. Bydd llenwi'r ffurflen hon yn ein galluogi i gael rhywfaint o wybodaeth gychwynnol amdanoch chi a'r math o gefnogaeth rydych chi'n chwilio amdani. Bydd yn ein helpu i wneud asesiad cychwynnol o'ch addasrwydd ar gyfer y gwasanaethau y gallwn eu cynnig. Atebwch yr holl gwestiynau. Mae'r ffurflen hon yn GYFRINACHOL i Gymorth ICAN a ddarperir gan Ganolfan Lles Tan Y Maen a Therapïau Siarad Parabl ac ni fydd y wybodaeth rydych chi'n ei darparu yn cael ei rhannu ag unrhyw un arall. Gellir ateb y rhan fwyaf o'r ffurflen hon yn Saesneg neu Gymraeg.
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