Name of person referred *
Post Code *
Telephone Number *
Date of Birth *
Age at time of registration
FemaleMalePrefer not to say
Carer Identified *
Carer Telephone Number
GP Name *
GP Telephone Number *
GP Address *
Organisation names of any mental health services being accessed
Current health issues and medication taken *
Disability : If yes please state *
Diagnosis i.e. Dementia, Depression, Schizophrenia etc
By whom was the diagnosis made by?
Keys signs of health changes i.e. are there any warnings of onset of epileptic seizures of T.I.A?
Are there any concerns we need to know about? i.e. diabetes, mobility, continence? *
Please indicate any safeguarding issues based on received information, past history and your knowledge. Please complete the below risk assessment to the best of your knowledge. It is important that we can provide a safe, supportive environment for all of our service users.
Risk to Self Harm *
Past history or abuse/traumatic experience that affects current moods and behaviours *
Risk to others (violence towards others) *
Risk to property (damage to property, theft, other) *
Physical health issues - any health issues or medication we may need to be aware of *
Name of referrer
Position / Team
Has consent been given by the client for information to be shared
The information provided will be held in the strictest confidence and in accordance with Nottinghamshire Mind and GDPR guidelines and data protection policies and procedures.
Please leave this field empty.