Nature in Mind Form - Service/Worker

  • Please complete all the fields

    You will not be able to move onto the next part of the form without completing all the questions.

  • * Esendex allows staff to send text messages to your phone via their computer. If you tick 'yes' we would store your name and mobile number in our Esendex account.

    You can find out more at Esendex for Business

  • Emergency contact

  • Medical information

  • *We recommend that you have an up to date tetanus injection.
  • Disclosure of information

  • In order for Framework to offer support and give advice, it may be necessary to liaise with other agencies and disclose relevant information.
  • Why do we need to share information about you?
  • To provide you with a service that is going to meet your needs, we may need to contact other organisations or individuals who are providing you support or who are involved with you in some other way that is relevant to the support we provide.

    This disclosure will only be done with your consent, except where;

    • The information provided indicates a serious risk to yourself or others
    • A serious threat of harm is made to a third party or it is considered that a child may be at risk. In this instance the information may be provided to Social Care or the Police
    • Disclosure is required by law or is necessary in the public interest
  • GP and Service Information

  • In accordance with the General Data Protection Regulation (2018), information supplied on this form is kept securely and will not be shared with any third party other than the support services listed above. I have read and understood the above information concerning how my data will be used and shared.
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  • Equality and Diversity Monitoring

    Optional information

  • We operate an equal opportunities policy across all our activities. Please tell us about yourself to help us monitor our efforts to achieve this.
  • Ethnic origin

  • Disability

  • The Equality Act (2010) describes disability as ‘a physical or mental impairment which has a substantial and long term adverse effect on your ability to carry out normal day to day activities’
  • If you are part of a service, or a worker referring another individual, please complete the risk assessment form that follows.


    Framework: Risk Assessment for Referring Agencies

  • We request that all referring agencies complete this form and referral form to the project or service they are referring to. This will not be used primarily as a basis for accepting or excluding people from Framework’s services, but will inform our own risk management strategy should we be able to offer accommodation or service.

    Please include information based upon your own work with the client, as well as any known history. If you feel that the information you pass on to us may need further qualification, please use the end of the form to pass on your concerns. It should be remembered that we are attempting to establish which of our services is best suited to support your client and manage the potential risks that others may pose to them as well as any potential risks they may pose to others. As such, we request that you involve your client in this process wherever possible, unless to do so would; in your opinion, increase the potential risk(s) posed. The object of this form is to get your assessment of the client which is, where possible, agreed with the client. If the client does not agree, or you have not involved them in the assessment, please say why on this form.

    Note: Framework cannot make an allocation decision without a completed risk assessment form.

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  • Framework will treat all risk assessment information with sensitivity. Sometimes we need to ask for more detail about an issue.

    If ‘yes’ please attach qualifying note, including whom we could approach for further information.

  • Dangerous Behaviour
  • Emotional/Mental Health Problems
  • Self-Care/Risk from Others
  • If you have ticked yes to any question please give a brief outline of behaviour/incidents. Also describe any work your organisation has carried out with the individual that relates to risk or any work that you or your client has agreed to carry out in the future.
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