INS(Integrated Neurological Services)

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Page 1

INS will hold, process and share your information and data with other health and social care professionals, such as your GP involved in your treatment. Please see our Privacy Notice for information on how we process your data, Thank you.





Referrer Contact Information













Referrer Address




Carer Information











(NHS number should be in this format e.g 000 000 0000)

INS is a charity supporting adults with neurological conditions. Alternative help may be available for under 18s. Please contact your GP, health authority, local council or other charities for advice. If you have any questions, please contact INS at admin@ins.org.uk or telephone 020 8755 4000

Carer Address






Carer Additional  Details

You give INS permission to contact the named person in the event of an emergency


If you select No so, We will request this information at assessment.
Emergency Contact







Health & Social Care Professionals involved 





Reason for referral 


Demographics

INS receive grants from local authorities / NHS and others. They require us to monitor the users of our services. We need to hold information about you to help us provide services. We may share this with NHS and local authorities in a way you cannot be identified. When we record and use your personal information, we only access it when we have good reason, only share what is necessary and don’t sell it to commercial organisations. Please note this part of the referral is not mandatory. 

Please select the relevant answers: 








Client Information











(NHS number should be in this format e.g 000 000 0000)

INS is a charity supporting adults with neurological conditions. Alternative help may be available for under 18s. Please contact your GP, health authority, local council or other charities for advice. If you have any questions, please contact INS at admin@ins.org.uk or telephone 020 8755 4000
Client Address






If you select No so, We will request this information at assessment.
Emergency Contact







Health & Social Care Professionals involved 





 If you have any questions, please contact INS at admin@ins.org.uk or telephone 020 8755 4000

INS needs the consent of the person you wish to refer to proceed further. Please contact INS on 020 8755 4000 or email admin@ins.org.uk for advice

INS is a charity supporting people with neurological conditions. Alternative help may be available. Please contact your GP, health authority, local council or other charities for advice

 If you have any questions, please contact INS at admin@ins.org.uk or telephone 020 8755 4000

NEUROLOGICAL CONDITION(S) and details of any other long-term conditions



Reason for referral 


Communication


Demographics

INS receive grants from local authorities / NHS and others. They require us to monitor the users of our services. We need to hold information about you to help us provide services. We may share this with NHS and local authorities in a way you cannot be identified. When we record and use your personal information, we only access it when we have good reason, only share what is necessary and don’t sell it to commercial organisations. Please note this part of the referral is not mandatory. 

Please select the relevant answers: 










 If you have any questions, please contact INS at admin@ins.org.uk or telephone 020 8755 4000

Client Information












(NHS number should be in this format e.g 000 000 0000)

INS is a charity supporting adults with neurological conditions. Alternative help may be available for under 18s. Please contact your GP, health authority, local council or other charities for advice. If you have any questions, please contact INS at admin@ins.org.uk or telephone 020 8755 4000
Client Address




You give INS permission to contact the named person in the event of an emergency


Emergency Contact







Health & Social Care Professionals involved





NEUROLOGICAL CONDITION(S) and details of any other long-term conditions



Reason for referral 


Communication


Safety/Safeguarding



Carer Details












(NHS number should be in this format e.g 000 000 0000)

INS is a charity supporting adults with neurological conditions. Alternative help may be available for under 18s. Please contact your GP, health authority, local council or other charities for advice. If you have any questions, please contact INS at admin@ins.org.uk or telephone 020 8755 4000

Carer Address




You give INS permission to contact the named person in the event of an emergency


Emergency Contact







Health & Social Care Professionals involved





Reason for referral 


 If you have any questions, please contact INS at admin@ins.org.uk or telephone 020 8755 4000