Bi-sexual Not stated What is your first language? How would you describe your religion or beliefs? (please state) Do you consider yourself to be disabled? Physical disability Mental disability If yes, please specify Learning disability Sensory disability Are you a carer? Yes No (Please tick) Do you have a carer? Yes No (Please tick) How do you describe your marital status? Married Separated (Please tick) Single Widowed Divorced Not stated Are you currently pregnant or on maternity Yes No leave? (Please tick) Do you have any children/dependants under Yes No 18, living with you? What is your work status? Full-time employed Part-time Volunteering Sick Unemployed Retired Additional Information I give my consent for The Kaleidoscope Plus Group to retain this information and understand that it will be stored confidentially and handled in full compliance with the Data Protection Act 1998 and The Kaleidoscope Plus policy on confidentiality. Group’s I understand the importance of keeping staff updated on significant changes in my health and circumstances. I understand that on occasions staff may request further information/advice from other persons involved in supporting me and I understand that on occasions staff may need to seek help on my behalf which has been explained to me. Date Client Signature ……………………………………………… ………………………….. Print name ………………………………………………. Referrer signature ……………………………………………. Date: …………………………. Print name ………………………………………………. For office use only: UC#: Name: Date:
Bi-sexual Not stated What is your first language? How would you describe your religion or beliefs? (please state) Do you consider yourself to be disabled? If yes, please specify Physical disability Mental disability Learning disability Sensory disability Are you a carer? (Please tick) Yes No Do you have a carer? (Please tick) Yes No How do you describe your marital status? (Please tick) Married Separated Single Widowed Divorced Not stated Are you currently pregnant or on maternity leave? (Please tick) Yes No Do you have any children/dependants under 18, living with you? Yes No What is your work status? Full-time employed Part-time Volunteering Sick Unemployed Retired Additional Information I give my consent for The Kaleidoscope Plus Group to retain this information and understand that it will be stored confidentially and handled in full compliance with the Data Protection Act 1998 and The Kaleidoscope Plus Group’s policy on confidentiality. I understand the importance of keeping staff updated on significant changes in my health and circumstances. I understand that on occasions staff may request further information/advice from other persons involved in supporting me and I understand that on occasions staff may need to seek help on my behalf which has been explained to me. Client Signature ……………………………………………… Date ………………………….. Print name ………………………………………………. Referrer signature ……………………………………………. Date: …………………………. Print name ………………………………………………. For office use only: UC#: Name: Date: