INS(Integrated Neurological Services)

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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.

Please tick to confirm you have read and understood the privacy notice.

Who are you seeking support for?

MyselfSomeone else

Do you have consent from this person to be referred to INS?

YesNo

Do you have a neurological condition?

YesNo

Are you an unpaid carer?

YesNo

Do you work in health or social care?

YesNo, Other

Referrer Contact Information

FormAssesmbly

TrueFalse

Title

First Name

Last Name

Telephone Number

Landline Number

Alternate Email

Organisation

Job Title

Borough

100 characters left.

Relationship to the person being referred?

200 characters left.

Organization(Incase they are relative or friend then we use this field)

Referrer Address

Street

Town/City

County

Post Code

Carer Information

Sub Status

Referrer

Title

First Name

Last Name

Mobile

Landline Number

Alternate Email

Borough

NHS Number

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

Date of Birth

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

Do you live with the person you are caring for?

YesNo

Carer Address

Street

Town/City

Post Code

County

You might want to give more information about you?

YesNo(If you are interested in further carer support from INS, we will request further information from you at a later date)

Org (Incase they don't want to give more information then we use this field)

Carer Additional Details

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

Consent to Contact Emergency Contact?

YesNo(You have selected the 'No' Option here so, We will request this information at a later date.)If you select No so, We will request this information at assessment.

Emergency Contact

Title

First Name

Last Name

Emergency Email

Emergency Telephone Number

Relationship to person being referred

Emergency Address

250 characters left.

Health & Social Care Professionals involved

GP Practice

For other GP Practice, specify here

Telephone Number

Are you known to your local NHS Community Neuro Therapy Team?

HounslowRichmondOther

Key professionals involved(Please includes dates and contact details)

2000 characters left.

Reason for referral

What care do you currently provide?

2000 characters left.

What help would you like from INS?

2000 characters left.

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:

Your gender:

Your ethnicity:

Your sexuality:

Your Religion:

Do you live alone?

Do you have a long-term condition?

Do you have a hearing or visual impairment Disability?

Client Information

Sub Status

Referrer

Title

First Name

Last Name

Telephone Number

Landline Number

Alternate Email

Borough

NHS Number

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

Date of Birth

Client Address

Street

Town/City

Post Code

County

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

Consent to Contact Emergency Contact?

YesNo(You have selected the 'No' Option here so, We will request this information at assessment.)If you select No so, We will request this information at assessment.

Emergency Contact

Title

First Name

Last Name

Emergency Email

Emergency Telephone Number

Relationship to person being referred

Emergency Address

250 characters left.

Health & Social Care Professionals involved

GP Practice

For other GP Practice, specify here

Telephone Number

Are you known to your local NHS Community Neuro Therapy Team?

HounslowRichmondOther

Key professionals involved(Please includes dates and contact details)

2000 characters left.

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

Primary Diagnosis

Multiple Sclerosis	Parkinson's Disease
Stroke	Brain Tumour
Other	Motor Neurone Disease
Guillain Barre Syndrome	Peripheral Nerve Injuries
Traumatic Brain Injury	Spinal Cord Injury

Specify Other Diagnosis

255 characters left.

Please tell us when you were diagnosed, and about your past medical history or any other condition

2000 characters left.

Reason for referral

What are your main difficulties / concerns?

2000 characters left.

What help would you like from INS?

2000 characters left.

Communication

Do you have any communication difficulties?

If yes, specify communication issues details here

2000 characters left.

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:

Your gender:

Your ethnicity:

Your sexuality:

Your Religion:

Do you live alone?

Do you have a long-term condition?

Do you have a hearing or visual impairment Disability?

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

Client Information

Sub Status

Self Referral

Salutation

Consent

First Name

Last Name

Telephone Number

Landline Number

Alternate Email

Borough

NHS Number

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

Date of Birth

Client Address

Street

Town/City

Post Code

County

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

Consent to Contact Emergency Contact?

YesNo(You have selected the 'No' Option here so, We will request this information at assessment.)

Emergency Contact

Title

First Name

Last Name

Emergency Telephone

Emergency Email

Relationship to person being referred

Emergency Address

250 characters left.

Health & Social Care Professionals involved

GP Practice

For other GP Practice, specify here

Telephone Number

Are you known to your local NHS Community Neuro Therapy Team?

HounslowRichmondOther

Key professionals involved(Please includes dates and contact details)

2000 characters left.

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

Primary Diagnosis

Multiple Sclerosis	Parkinson's Disease
Stroke	Brain Tumour
Other	Motor Neurone Disease
Guillain Barre Syndrome	Peripheral Nerve Injuries
Traumatic Brain Injury	Spinal Cord Injury

Specify Other Diagnosis

250 characters left.

Please tell us when you were diagnosed, and about your past medical history or any other condition

2000 characters left.

Reason for referral

What are the main difficulties / concerns to the person referred by you?

2000 characters left.

What help would you like from INS?

2000 characters left.

Communication

Does the person you are referring have any communication difficulties?

If yes, specify communication issues details here

2000 characters left.

Safety/Safeguarding

Does the person you are referring has the safety/safeguarding issues?

If yes, specify safeguarding issues here

2000 characters left.

Does the client's main carer also require support from INS?

YesNo

Carer Details

Sub Status

Self Referral

Consent

Salutation

First Name

Last Name

Telephone Number

Landline Number

Alternate Email

Borough

NHS Number

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

Date of Birth

Do you live with the person you are caring for?

YesNo

Carer Address

Street

Town/City

Post Code

County

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

Consent to Contact Emergency Contact?

YesNo(You have selected the 'No' Option here so, We will request this information at assessment.)

Emergency Contact

Title

First Name

Last Name

Emergency Telephone

Emergency Email

Relationship to person being referred

Emergency Address

250 characters left.

Health & Social Care Professionals involved

GP Practice

For other GP Practice, specify here

Telephone Number

Are you known to your local NHS Community Neuro Therapy Team?

HounslowRichmondOther

Key professionals involved(Please includes dates and contact details)

2000 characters left.

Reason for referral

What are the main difficulties / concerns to the person referred by you?

2000 characters left.

What help would you like from INS?

2000 characters left.

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

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