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Intake Assessment Form
I need an Intake Assessment Form for my mental health clinic that includes detailed risk assessment sections and cultural considerations, ensuring compliance with NHS standards and GDPR requirements for implementation by March 2025.
1. Personal Information: Basic demographic data, contact details, and identifiers including name, date of birth, address, phone, email
2. Emergency Contacts: Next of kin and alternative contact information including relationship, contact details and access permissions
3. Consent Declaration: Data processing and information sharing permissions, including GDPR compliance statements and opt-in/opt-out choices
4. Primary Assessment Areas: Core evaluation criteria relevant to service provision, including presenting needs, current situation, and support requirements
5. Risk Assessment: Initial evaluation of key risks and safety concerns, including immediate safeguarding needs and risk mitigation strategies
1. Medical History: Detailed health information including current conditions, medications, allergies, and previous treatments - used in healthcare settings
2. Safeguarding Concerns: Additional protection needs assessment including vulnerability factors and specific safeguarding measures required
3. Cultural/Religious Requirements: Specific cultural or religious considerations that may impact service delivery or support arrangements
1. Privacy Notice: Detailed information about data processing, storage, sharing, and individual rights under GDPR
2. Service-Specific Assessments: Additional specialized assessment tools and criteria specific to particular service areas
3. Consent Forms: Supplementary consent documentation for specific services or information sharing arrangements
Authors
Client
Service User
Personal Data
Special Category Data
Consent
Assessment Date
Service Provider
Emergency Contact
Next of Kin
Legal Representative
Capacity
Risk Level
Care Plan
Assessment Period
Referral Source
Primary Need
Support Requirements
Data Controller
Professional Standards
Confidential Information
Safeguarding Concern
Priority Status
Assessment Outcome
Review Date
Service Type
Authorization
Treatment Plan
Initial Assessment
Follow-up Assessment
Consent and Authorization
Data Protection
Confidentiality
Information Sharing
Emergency Contacts
Medical History
Risk Assessment
Service Needs
Capacity Assessment
Safeguarding
Access to Records
Privacy Notice
Communication Preferences
Cultural Requirements
Accessibility Needs
Health and Safety
Service Eligibility
Assessment Review
Complaint Procedures
Declaration and Signature
Professional Assessment
Referral Information
Support Requirements
Rights and Responsibilities
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