CHAT Tool - Offender Health Research Network

Mental Health Assessment No Yes
Is the young person currently impaired e.g. intoxication/injury/disability
Does the young person have capacity to give consent for assessment
Name of professional completing capacity assessment:
Signature:
Date:
Neurodisability Assessment No Yes
Is the young person currently impaired e.g. intoxication/injury/disability
Does the young person have capacity to give consent for assessment
Name of professional completing capacity assessment:
Signature:
Date:
Consent Process
Who is providing consent (please tick)
Young person
Parent/legal guardian/person holding parental responsibility
Consent for Assessment
I understand that the information I provide as part of the CHAT will remain confidential to those staff involved in
my care and treatment unless someone identifies that there is, or is likely to be, a risk of significant harm to
myself or others.
NB: ‘Significant’ means major and ‘harm’ includes impairment of health and development as well as ill-treatment
or self-harm.
Name:
Signature:
Date:
Surname:
DOB:
Forenames:
NHS Number:
CHAT Tool Secure Estate (Version 3 - June 2013)
2 | P age