Nature in Mind Referrals

Please complete all the fields

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

You can find out more at Esendex for Business

Emergency contact

Medical information

Disclosure of information

Why do we need to share information about you?

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

Equality and Diversity Monitoring

Optional information

Gender

Ethnic origin

Religion and Belief

Sexual Orientation

Disability

If you are part of a service, or a worker referring another individual, please complete the risk assessment form that follows.

STRICTLY PRIVATE & CONFIDENTIAL

Framework: Risk Assessment for Referring Agencies

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.

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.