Safe contact notes Next of kin who can we contact in an emergency? – Name Relationship Contact information Safe contact notes Accessibility requirements Does this client have any Yes If yes, please provide details: ☐ accessibility requirements No☐ (for example, hearing Don’t Know ☐ loop, braille documents) Does this client require an If yes, please provide details: Yes ☐ interpreter? No☐ Don’t Know ☐ Client equalities monitoring How would this client describe ☐ Female their gender? Male ☐ In another way: _________________ Is their current gender different to Yes ☐ the sex they were assigned at birth? No ☐ Don’t know ☐ Do they consider themselves to Physical ☐ have any kind of disability? Learning ☐ (please tick any that Mental Health ☐ Deaf/ hearing impaired ☐ Blind/ visually impaired ☐ Something Don’t Know ☐
Safe contact notes Next of kin – who can we contact in an emergency? Name Relationship Contact information Safe contact notes Accessibility requirements Does this client have any accessibility requirements (for example, hearing loop, braille documents) Yes ☐ No☐ Don’t Know ☐ If yes, please provide details: Does this client require an interpreter? Yes ☐ No☐ Don’t Know ☐ If yes, please provide details: Client equalities monitoring How would this client describe their gender? Female ☐ Male ☐ In another way: _________________ Is their current gender different to the sex they were assigned at birth? Yes ☐ No ☐ Don’t know ☐ Do they consider themselves to have any kind of disability? (please tick any that Physical ☐ Learning ☐ Mental Health ☐ Deaf/ hearing impaired ☐ Blind/ visually impaired ☐ Something Don’t Know ☐
PDVG-HWA-Referral.docx