Client Details

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Contact Details

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Next of Kin, Emergency Information

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Medical Conditions including any Surgeries and Diagnosis if Relevant

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Health Care Information

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Goals and Aspirations

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I understand that:
  • This organisation owns these records.
  • Information within these records will be shared with other staff within the
  • organisation on and only when staff require the information to carry out their duties
  • I can ask to see records and receive a copy
  • Records are archived for a set period according to policy and procedure
  • I understand that all information obtained will be kept confidential.
To the best of my knowledge, the information provided in this form is true and correct: