Consumer Information
CAR 536 /
Carer Alpha Code
Care Recipient Alpha Code
Key Worker
Referred
Approved
CARE RECIPIENT
Family Name / Given Names
Date of Birth / Age
Current Address / Post Code
Contact Numbers / Email Address
Gender / Marital Status
Country of Birth / Religion
Preferred Language / Interpreter required
Income Type / Accommodation
Diagnosis(s) / Medications
Safety / Risk alert / Social alert
Medical alert / Allergies, Dietary alert
CARER
Family Name / Given Names
Date of Birth / Age
Current Address / Post Code
Contact Numbers / Email Address
Gender / Marital Status
Country of Birth / Religion
Preferred Language / Interpreter required
Income Type / Accommodation
Diagnosis(s) / Medications
Safety / Risk alert / Social alert
Medical alert / Allergies, Dietary alert

Other Support Services, treating professionals Involved and Significant others:

Name / Organisation / Contact Number

History

Family Name / Given Name
Date of Birth / Age
Gender / Relationship to Client
Current Address / Post Code
Contact Numbers / Interpreter Required
Behavioural Status / No Risk / Yes Risk / Unknown
Does the client have a history of aggressive, violent, disturbed, inappropriate or offensive behaviour?
Is there a history of client presenting at office under the influence of alcohol or drugs?
Mental Health Status
Are there any specific abnormalities in mental state which may present a risk to staff e.g. command hallucinations, morbid jealousy?
Is there a history of violent acts or threats?
Has a Risk Assessment and Management plan been completed?

Where a risk is identified above a copy of the management plan is to be attached to this document

Common Requests / Appropriate Responses
Risks at Presentation - detail / Response
Exit Date:
Reviewed By: / Signed:
Team Leader: / Manager:
Doc No: CAR 536 / Version No: 1 / Date of Issue: 18/06/2015
Author Title: MB / Authoriser Title: DSD / Approver Title: CEO
CONTROLLED COPY / Uncontrolled Copy When Printed
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