Religion/Belief None Jewish Any other religion Christian (all denominations) Muslim Not known Buddhist Sikh Does not wish to disclose Hindu Sexual orientation Heterosexual Gay Man Lesbian Bisexual Other Does not wish to disclose Yes No Don’t Know Do not wish to disclose Transgender Yes No Don’t Know Do not wish to disclose Ex-Armed forces personnel Additional risk information Risk/Support Areas Potential risk Details or needs in If Yes please add further details this area Yes No Drugs Alcohol Yes No Physical Health Yes No Yes No Mental Health Self Harm/Suicide Yes No Offending Yes No Arson Yes No Yes No Sex Offences, and Offences Against a Person Under the Age of 18 Violence/Aggressive Yes No Behaviour Yes No Financial Family/Relationships Yes No Risk of Yes No Accommodation Breakdown The client is signing to give consent that the information in this form is correct and can be shared with services within the MainStay. Signed by client: Date:
Religion/Belief None Christian (all denominations) Buddhist Hindu Jewish Muslim Sikh Any other religion Not known Does not wish to disclose Sexual orientation Heterosexual Gay Man Lesbian Bisexual Other Does not wish to disclose Transgender Yes No Don’t Know Do not wish to disclose Ex-Armed forces personnel Yes No Don’t Know Do not wish to disclose Additional risk information Risk/Support Areas Potential risk or needs in this area Details If Yes please add further details Drugs Yes No Alcohol Yes No Physical Health Yes No Mental Health Yes No Self Harm/Suicide Yes No Offending Yes No Arson Yes No Sex Offences, and Offences Against a Person Under the Age of 18 Yes No Violence/Aggressive Behaviour Yes No Financial Yes No Family/Relationships Yes No Risk of Accommodation Breakdown Yes No The client is signing to give consent that the information in this form is correct and can be shared with services within the MainStay. Signed by client: Date: