CHAT Tool - Offender Health Research Network

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First Language: Interpreter Required: Religion: Ethnic White, British Asian, Bangladeshi Mixed, White &Asian Origin White, Irish Asian, Indian Mixed, Other White, Other Asian, Pakistani Other Ethnic Group Black, African Chinese Not Available Black, Caribbean Asian, Other Black, Other Mixed, White & Black G.P. Name: Address: Telephone: Legal Status Is the young person a looked after child (tick) Yes Legal status: No Please see the CHAT manual for further information about how to proceed if a young person is looked after under s31 or s.20 of the Children Act 1989. Children and young people remanded to custody will now all be looked after children for the period of the remand s.104 Legal Aid, Sentencing and Punishment of Offenders Act (LASPOA) 2012 Next of Kin Relationship (tick) Mother Father Other describe: Name: Address: Telephone: Mobile: First Langauge: Interpreter Required: Person/s with Parental Responsibility: Dependants List dependant children, siblings, parents. Include name and age/care needs. Also include any dependent pets: Have arrangements been made for their care No Yes If NO add to Immediate Care Plan and refer to Social Services Surname: DOB: Forenames: NHS Number: CHAT Tool Secure Estate (Version 3 - June 2013) 5 | P age
Medical and Psychiatric History Document any relevant medical or psychiatric history from accompanying records, including medication Developmental Needs Does the young person have any identified developmental needs including learning difficulties, speech and language impairment or autistic spectrum disorder Yes No If yes please explain below: Surname: DOB: Forenames: NHS Number: CHAT Tool Secure Estate (Version 3 - June 2013) 6 | P age
Page 1 and 2: Comprehensive Health Assessment Too
Page 3 and 4: Mental Health Assessment No Yes Is
Page 5: CHAT RECEPTION SCREEN • Every you
Page 9 and 10: 5. Do you have DIABETES MELLITUS If
Page 11 and 12: Reception Screen Section Two: Subst
Page 13 and 14: 6. Is the young person withdrawing
Page 15 and 16: Tick No or Yes as appropriate for e
Page 19 and 20: Documents you have access to at the
Page 21 and 22: CHAT Immediate Care Plan Name: DOB:
Page 23 and 24: Substance Misuse Service No Yes No
Page 25 and 26: Is the young person subject to a CH
Page 27 and 28: MMR BCG HPV Hep A Hep B Typhoid Flu
Page 43 and 44: Disability and Impairment Invitatio
Page 45 and 46: Physical Health Summary/Review Summ
Page 47 and 48: Do the accompanying documents or in
Page 49 and 50: Drug/Alcohol History and Misuse (Co
Page 51 and 52: Drug/Alcohol History and Misuse (Co
Page 53 and 54: Withdrawal - These symptoms are der
Page 55 and 56: DRUG/ALCOHOL USE Where do you usual
Page 57 and 58:
Employment E.g. lack of qualificati
Page 59 and 60:
Risk Review Tick No or Yes as appro
Page 61 and 62:
CHAT MENTAL HEALTH ASSESSMENT • E
Page 63 and 64:
Tick No or Yes as appropriate for e
Page 65 and 66:
Page 67 and 68:
Page 69 and 70:
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CHAT NEURODISABILITY ASSESSMENT •
Page 85 and 86:
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After a head injury or accident som
Page 89 and 90:
NARRATIVE TASK Ask the young person
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Learning Disability and Educational
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INFORMATION FROM THE YOUNG PERSON T
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Autistic Spectrum Disorder Start by
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Section 3: In social interactions d
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Name: CHAT CARE PLAN DOB: Date: NHS
Page 103 and 104:
Problem/Issue Intervention/Action R
Page 105 and 106:
Initial Weight: Date: Discharge Wei
Page 107 and 108:
Summary of any current or previous
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