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Assessment Form
Name
Date/Time
Address
Clearpoint No.
Ward Location
Phone
Parent/Carer Phone
Name & Address of Doctor/GP Practice
Date of Birth
Age
Gender Identity
Female
Male
Non-binary
Transgender
Other (please specify)
If 'Other' please specify
Do you identity as LGBT+
Yes
No
Prefer not to say
If 'Yes', please specify
Ethnicity
Asian Bangladeshi
Asian Indian
Asian Pakistani
Asian Other
Asian Sri Lankan
Black African
Black British
Black Caribbean
Black Other
Chinese
Mixed Other
Mixed W & Asian
Mixed W & BA
Mixed W & BC
Not Known
White British
White Irish
White Other
Other
If' Other' please specify
Disability?
Yes
No
If 'Yes', please specify
Looked After Child
Yes
No
Care Leaver
Yes
No
Young Carer (do you look after someone else?)
Yes
No
Support Network (family/friends/relatives and significant people)
If you are a human seeing this field, please leave it empty.
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Young People
Counselling
Outreach
Young People’s Team
Parents/Carers
Professionals
About CDI
Meet the Team
Working for CDI
Get Involved
News & Resources
FAQs
Contact
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