CHAT Tool - Offender Health Research Network

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Tick No or Yes as appropriate for each question and include additional notes No Yes Does your worry stop you from doing things, or interfere with how well you get on with your friends or family If Yes, does the worry become so much that you start to panic e.g. heart racing, breathless, shaky, thoughts that something bad is going to happen to them Do you worry about going into particular situations e.g. a crowded room or situations with a large number of your peers (agoraphobia/social phobia) Do these symptoms get in the way of normal life e.g. at home, education, work settings or with friends ACTION FOR CARE PLAN Surname: DOB: Forenames: NHS Number: CHAT Tool Secure Estate (Version 3 - June 2013) 71 | P age
Tick No or Yes as appropriate for each question and include additional notes No Yes POST-TRAUMATIC STRESS Has anything very frightening or awful ever happened to you or have you seen anything awful happen to your family or friends (car accidents; violence; been physically or sexually hurt by others e.g. being hit or touched in a way that makes them feel uncomfortable or a sexual attack; saw someone die) If Yes, have you thought much about what happened in the last 2 months If Yes, do you have vivid memories of what happened; flashbacks so that you can see it all again in your mind Does thinking about what happened make you feel sad Surname: DOB: Forenames: NHS Number: CHAT Tool Secure Estate (Version 3 - June 2013) 72 | P age
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Comprehensive Health Assessment Too
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Mental Health Assessment No Yes Is
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CHAT RECEPTION SCREEN • Every you
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Medical and Psychiatric History Doc
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5. Do you have DIABETES MELLITUS If
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Reception Screen Section Two: Subst
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6. Is the young person withdrawing
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Tick No or Yes as appropriate for e
Page 17 and 18:
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 29 and 30: Tick No or Yes as appropriate for e
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 71: Tick No or Yes as appropriate for e
Page 83 and 84: CHAT NEURODISABILITY ASSESSMENT •
Page 87 and 88: After a head injury or accident som
Page 89 and 90: NARRATIVE TASK Ask the young person
Page 91 and 92: Learning Disability and Educational
Page 93 and 94: INFORMATION FROM THE YOUNG PERSON T
Page 95 and 96: Autistic Spectrum Disorder Start by
Page 97 and 98: Section 3: In social interactions d
Page 101 and 102: 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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CHAT Tool - Offender Health Research Network

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