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Referral Intake Form
"I need a Referral Intake Form for my mental health clinic in Cardiff that complies with NHS Wales standards and includes specific sections for risk assessment and previous treatment history, to be implemented by March 2025."
1. Client Information: Basic personal details, contact information, and identifiers of the client being referred
2. Referral Source: Details of referring individual/organization and their relationship to client
3. Reason for Referral: Primary concerns and specific needs prompting the referral
4. Consent Declaration: Client's explicit consent for information sharing and referral processing
5. Privacy Notice: Information about data processing and protection rights under UK GDPR and Data Protection Act 2018
1. Medical History: Relevant medical information for health-related referrals
2. Risk Assessment: Evaluation of potential risks to client or others, particularly for vulnerable individuals or mental health cases
3. Support Network: Details of family members, carers, or other support persons for cases requiring ongoing support coordination
4. Emergency Contacts: Contact details for emergency situations in high-risk cases or for vulnerable individuals
1. Supporting Documentation: Relevant reports, assessments, or additional information supporting the referral
2. Consent Forms: Copies of signed consent forms and authorizations
3. Service Information: Details about available services and eligibility criteria
4. Privacy Policy: Detailed data protection and privacy information compliant with UK GDPR and Data Protection Act 2018
Authors
Client
Service Provider
Referral
Confidential Information
Personal Data
Special Category Data
Consent
Emergency Contact
Services
Professional Standards
Data Protection Legislation
Safeguarding
Care Plan
Assessment
Authorized Representative
Legal Guardian
Priority Level
Risk Level
Service Requirements
Support Network
Healthcare Professional
Treatment Plan
Previous Service History
Referral Date
Effective Date
Consent
Data Protection
Confidentiality
Emergency Contact
Medical History
Risk Assessment
Service Requirements
Safeguarding
Information Sharing
Privacy Notice
Record Keeping
Access to Records
Professional Standards
Eligibility Criteria
Priority Assessment
Support Requirements
Previous Services
Contact Preferences
Accessibility Requirements
Declaration
Authentication
Third Party Disclosures
Rights and Responsibilities
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