Clear Mind Care
Intake Form

    1. Referral Details

    2. Applicant’s Personal Information

    3. Current Living Situation

    Is the Applicant at Risk of Eviction or Homelessness?

    4. Mental Health Diagnosis & Background

    Is the Applicant Under Current Treatment?

    Any Hospital Admissions in the Past 12 Months?

    Known to Crisis Resolution Home Treatment Teams?

    5. Support Needs

    Does the Applicant Require Assistance with Medication?

    6. Risk Assessment

    Any History of Harm to Self or Others?

    Any History of Substance or Alcohol Misuse?

    Does the Applicant Have Any Current Safeguarding Issues?

    7. Goals for Supported Living

    8. Other Relevant Information

    Is the Applicant Currently Engaged in Any Work, Education, or Volunteering?

    Does the Applicant Have Any Criminal Record or Current Legal Matters?

    9. Consent to Referral

    10. Referrer’s Declaration

    11. Supporting Documents (Please Attach)

    – Recent Mental Health Assessment
    – Care Plan (if available)
    – Risk Assessment (if available)
    – Hospital Discharge Summary (if applicable)
    – Proof of ID and Address
    – Any Other Relevant Documents (e.g., OT Assessment)