Community Enquiry FormCommunity (EN - New) Client Full Name * Date of Form Completion * Client Date of Birth * Client Gender * Client Home Address * Can Mail Be Sent? YesNo Current Housing Owner/OccupierPrivate RentedHousing AssociateLocal AuthorityNo Fixed AbodeTemporary AccommodationHospitalOther Client Telephone Number * Can We Phone? YesNo Can We Leave a Voicemail? YesNo Client Email Address Can Email Be Sent? YesNo GP Practice Address GP Practice Telephone Number Client Preferred Language * EnglishWelshBengaliCantoneseHindiMandarinPolishUkrainianUrduBSL/SSEMakatonOther (Please State) Other Language (If Applicable) Client preferred method of contact (Telephone, email, post, other) * Consent given for information to be stored securely to CADMHAS? * YesNo **Issue(s) requiring advocacy support (Please note clients will be asked to prioritise a maximum of two issues per advocacy case)** 1: * 2: * What actions would you like the advocate to take to resolve the issue(s)? Support Needs * Autism Spectrum Disorder Brain Injury Cognitive Impairment Dementia Frailty/Temporary Illness Hearing Impairment History of Offending Learning Disability (ies) Mental Health Issues Older People Physical Disability (ies) Pregnant PSNI (Physical, sensory or neurological impairment) SPI (Serious or severe physical illness) Substance Misuse Veteran Other Please provide any other/additional relevant information regarding support needs Any risk? (i.e. history of displaying aggressive behaviours) * YesNo Any known triggers? * Type of risk (Please include any personal risks, as well as environmental factors (i.e. verbal abuse, difficulty accessing property, animals etc)) * Risk Management Method(s) * Enquiry Organisation (if applicable) Name of Enquirer * Enquirer Job Title * Enquirer Contact Number * Enquirer Email Address * Emergency Contact, Family or Friend: Relationship to Client Emergency Contact, Family or Friend: Name Emergency Contact, Family or Friend: Tel No Emergency Contact, Family or Friend: Email Emergency Contact, Family or Friend: Address (including county and postcode) Does the client consent to us contacting their emergency contact in the case of an emergency? Yes No Submit If you are human, leave this field blank. This post is also available in: Cymraeg
