Multi Agency Public Protection Arrangements (MAPPA) Referral for Level 2/3 Management

Size: px
Start display at page:

Download "Multi Agency Public Protection Arrangements (MAPPA) Referral for Level 2/3 Management"

Transcription

1 Multi Agency Public Protection Arrangements (MAPPA) Referral for Level 2/3 Management ALL referrals must demonstrate what the benefit of active multi-agency management would be Is the Offender already subject to MAPPA? Yes Category 1 Category 2 No Not Known IF YES: Please consult with the Police Risk Management Officer (Category 1) or Lead Agency - Probation, YOT, Mental Health, (Category 2) who is currently managing the offender to discuss the reason for the referral and state the name of the person consulted and the date. Lead Agency Name Date Comments following consultation 1. Offender Information Complete in all Cases Family name: First name: Alias: Date of birth: Ethnicity: Gender: Disability/diversity considerations: Crams number: ViSOR number: NHS number: Last known address: Current address, including prison, hospital etc Proposed release address Page 1 of 7

2 2. Reason for Referral Complete in all Cases Reason for referral: What inter-agency work has been undertaken so far? How will active multi-agency management add value to the management of the risk(s) of serious harm? Who is identified as being at risk? What is the nature of the risk? What is the likelihood of further offending of this type? Imminency of the risk? (please include any evidence to suggest the offender is taking active steps to make it happen) Any potential disclosure issues? Page 2 of 7

3 Any accommodation issues? 3 Risk Assessment complete if currently subject to MAPPA and the referral is being submitted by lead agency IF NOT go to Section 5 If Category 1 offender Offence and relevant sentence/caution date. Please provide details of offence(s) Risk Matrix 2000 Level (include date assessment completed) Comments: (include overall risk level managed at) If Category 2 offender specify Lead - Probation Mental Health YOT Offence and relevant sentence dates including any current Community Order/Resettlement details. Please provide details of offence(s) Risk Assessment Tool used OASys SARA ASSET OTHER (please specify) Please provide copy of risk assessment tool except OASys Assessed Level of Risk of Harm as determined by the Risk Assessment Page 3 of 7

4 4 Risk Management Case managed by the Police Has a risk management plan been completed? Yes/No Date of plan Level of home visiting: Summary of risk management plan: Risk Management Officer: Case Managed by Probation Has a risk management plan been completed? Yes/No Date of plan Summary of risk management plan: Offender Manager: Case Managed by YOT Has a risk management plan been completed? Yes/No Date of plan: Summary of risk management plan: Case Manager: Case managed by Mental Health Has a risk management plan been completed Yes/No Date of plan: Details of plan: Case Manager: Legal status: Inpatient/current hospital: Page 4 of 7

5 Next tribunal date: Next Care Plan Approach date: 5 Victim Concerns Outline any concerns about the victim of the index offence or potential victims: Has the victim taken up the Victim Liaison Service? If YES: Give contact details of VLO Are there any domestic abuse concerns? If YES, answer questions a to e below. a. What are they? b. Has the victim been referred to MARAC? c. Has a MARAC meeting been held/is a meeting due to be held? d. Date of MARAC meeting (if known) e. Actions from MARAC 6 Safeguarding Complete if relevant Child Protection Concerns (continue an additional sheet if required) Are there any child protection concerns? If YES, answer questions a to d below. a. What are they?. b. Has your agency submitted a child concern notification. c. Is there an allocated Social Worker? If so, please give details. Page 5 of 7

6 d. Is the child or children currently subject to a Child Protection Plan? Vulnerable Adult Concerns (continue on additional sheet if required) Are there any vulnerable adult concerns? IF YES, answer questions a to g below a. Has your agency submitted a vulnerable adult notification: b. c. Date of birth: d. Gender: e. Does this person live with the offender? f. Relationship to offender: g. Name of Social Worker (if relevant): 7 Additional MAPPA invitees Are there any agencies/named individuals that can contribute to the risk assessment/management that need to be invited to the meeting. Invitee 1 Invitee 2 Page 6 of 7

7 Invitee 3 Referring Agency Information Date sent to Line Manager: Are you completing this referral on behalf of another agency? Yes No If YES provide details of agency Endorsement by Line Manager Grade: Date signed by Line Manager: Line Manager s comments: Please send it via secure to ntawnt.mappa@nhs.net, for the attention of the Safeguarding MAPPA Practitioner Lead (NTW) Date sent: Page 7 of 7

18 to 21 year olds and housing costs

18 to 21 year olds and housing costs 18 to 21 year olds and housing costs First published: 04 April 2017 (version 1) Contents Housing costs not payable Claimants not in all work related requirements Claimants temporarily exempted from all

More information

Advice to inform Government Office negotiations with local areas on developing improvement targets

Advice to inform Government Office negotiations with local areas on developing improvement targets NI32: Repeat Incidents of Domestic Violence Advice to inform Government Office negotiations with local areas on developing improvement targets This guidance should be read in conjunction with the Target

More information

Impact of the Vetting & Barring Scheme. Julian Topping Head of Workplace Health NHS Employers

Impact of the Vetting & Barring Scheme. Julian Topping Head of Workplace Health NHS Employers Impact of the Vetting & Barring Scheme Julian Topping Head of Workplace Health NHS Employers Safeguarding Vulnerable Groups Act 2006 Key changes Scope of safeguarding extended - people included on the

More information

The Company is responsible for the care and safeguarding of some of the most vulnerable people in society.

The Company is responsible for the care and safeguarding of some of the most vulnerable people in society. Page 1 of 6 Title of Policy: Disclosure and Barring Section: Human Resources Statement The Company is responsible for the care and safeguarding of some of the most vulnerable people in society. This responsibility

More information

Consent for Purposes of Treatment, Payment and Healthcare Operations

Consent for Purposes of Treatment, Payment and Healthcare Operations Consent for Purposes of Treatment, Payment and Healthcare Operations I consent to the use or disclosure of my protected health information by Neuropsych Associates for the purpose of diagnosing or providing

More information

Barnardo s Scotland. Protection of Vulnerable Groups (Scotland) Act 2007 Response to Consultation on policy proposals for secondary legislation

Barnardo s Scotland. Protection of Vulnerable Groups (Scotland) Act 2007 Response to Consultation on policy proposals for secondary legislation Barnardo s Scotland Protection of Vulnerable Groups (Scotland) Act 2007 Response to Consultation on policy proposals for secondary legislation Introduction Barnardo s Scotland manages over 60 services

More information

Child Safeguarding Policy

Child Safeguarding Policy Child Safeguarding Policy 2017-2018 Policy Reference: Policy/HOME053 V1 Policy/HOME052 V1 Approved by: ELT Date approved: 10/06/2017 1. Scope and objectives 1.1. The purpose of this policy is to ensure

More information

CONTRACTUAL PURPOSES. Last Updated: 8 Oct 18

CONTRACTUAL PURPOSES. Last Updated: 8 Oct 18 On signing this Tenancy Agreement you will become an RBH Tenant. To deliver our full range of services to you, the personal information you have provided will be processed in a number of ways as set out

More information

Annual Report: SAFEGUARDING ADULTS AND CHILDREN

Annual Report: SAFEGUARDING ADULTS AND CHILDREN Annual Report: SAFEGUARDING ADULTS AND CHILDREN Children, young people, vulnerable adults and victims of domestic abuse are considered in all interactions with service users and carers. Safeguarding, protecting

More information

Application for Employment

Application for Employment Application for Employment Please complete this form fully, using block capital letters. The information that you supply on this form will be treated in confidence. Applications are invited from people

More information

DRAFT. PSi CELL SHARING RISKASSESSMENT/ RISKOF HARM TO OTHERS

DRAFT. PSi CELL SHARING RISKASSESSMENT/ RISKOF HARM TO OTHERS PSi CELL SHARNG RSKASSESSMENT/ RSKOF HARM TO OTHERS Purpose. This Prison Service nstruction {PS) replaces PS 26/2002 on Cell- Sharing Risk Assessment and accompanying forms which were introduced on 20

More information

Housing Application Form

Housing Application Form Housing Application Form Please read this form carefully and fill in details for you and the joint applicant if there is one (a joint applicant is an adult applying for a joint tenancy with you). Fill

More information

NEW JERSEY NOTICE FORM

NEW JERSEY NOTICE FORM 1 NEW JERSEY NOTICE FORM Notice of Psychologists' Policies and Practices to Protect the Privacy of Your Health Information THIS NOTICE DESCRIBES HOW PSYCHOLOGICAL AND MEDICAL INFORMATION ABOUT YOU MAY

More information

Ministry Of Health Registration of Interest

Ministry Of Health Registration of Interest Ministry Of Health Registration of Interest Service Outcomes and Service Providers Social Bond Pilot (Note: The ROI for Intermediaries will follow in 2014) Part 1 Instructions and Supporting Information

More information

Thames Valley Police and Crime Commissioner. Victims Services Commissioning Intentions. April 2014

Thames Valley Police and Crime Commissioner. Victims Services Commissioning Intentions. April 2014 Thames Valley Police and Crime Commissioner Victims Services Commissioning Intentions April 2014 1.0 Purpose To outline the commissioning intentions, both interim and longer term, of the Thames Valley

More information

Exclusion from West Kent homes

Exclusion from West Kent homes Exclusion from West Kent homes A question and answer guide What is exclusion? Exclusion means West Kent will not be able to offer you a home. Why might West Kent exclude me from their homes? West Kent

More information

Texas At-Risk Youth Services Project (ARYSP) Legislative Budget Board Criminal Justice Data Analysis Team October 2011

Texas At-Risk Youth Services Project (ARYSP) Legislative Budget Board Criminal Justice Data Analysis Team October 2011 Texas At-Risk Youth Services Project (ARYSP) Legislative Budget Board Criminal Justice Data Analysis Team October 2011 Goal of ARYSP Improve the delivery of services to at-risk youth in Texas At-risk youth

More information

Vote Social Development

Vote Social Development G.60 MINISTRY OF SOCIAL DEVELOPMENT ANNUAL REPORT Vote Social Development Output Expense (Multi-year Appropriation 61 ): Administering Support for the Mental Health and Employment Social Bond Pilot This

More information

EDUCATION, LIFELONG LEARNING AND CULTURE COMMITTEE AGENDA. 18th Meeting, 2010 (Session 3) Wednesday 9 June 2010

EDUCATION, LIFELONG LEARNING AND CULTURE COMMITTEE AGENDA. 18th Meeting, 2010 (Session 3) Wednesday 9 June 2010 ELLC/S3/10/18/A EDUCATION, LIFELONG LEARNING AND CULTURE COMMITTEE AGENDA 18th Meeting, 2010 (Session 3) Wednesday 9 June 2010 The Committee will meet at 10.00 am in Committee Room 1. 1. Local government

More information

MINNESOTA CRIME VICTIMS REPARATIONS CLAIM FORM Complete and submit to:

MINNESOTA CRIME VICTIMS REPARATIONS CLAIM FORM Complete and submit to: Date Received: MINNESOTA CRIME VICTIMS REPARATIONS CLAIM FORM Complete and submit to: Claim Number: (Office Use Only) Minnesota Crime Victims Reparations Board 445 Minnesota Street, Suite 2300 St. Paul

More information

Adults Health and Care Contact Assessment Resolution Team (C.A.R.T) and the Multi Agency Safeguarding Hub (MASH)

Adults Health and Care Contact Assessment Resolution Team (C.A.R.T) and the Multi Agency Safeguarding Hub (MASH) Adults Health and Care Contact Assessment Resolution Team (C.A.R.T) and the Multi Agency Safeguarding Hub (MASH) 1 CART The Contact Assessment Resolution Team C A R T i s a n i n t e g r a t e d s e r

More information

COMPLIANCE & SUPPORT. Inquiry Report London Mill Hill Congregation of Jehovah s Witnesses. Registered Charity Number

COMPLIANCE & SUPPORT. Inquiry Report London Mill Hill Congregation of Jehovah s Witnesses. Registered Charity Number COMPLIANCE & SUPPORT Inquiry Report London Mill Hill Congregation of Jehovah s Witnesses Registered Charity Number 1065638 A statement of the results of an inquiry into the London Mill Hill Congregation

More information

**CONTINUATION COVERAGE RIGHTS UNDER COBRA**

**CONTINUATION COVERAGE RIGHTS UNDER COBRA** **CONTINUATION COVERAGE RIGHTS UNDER COBRA** Federal law requires certain employers sponsoring group health plan coverage to offer their employees (and his or her enrolled family members) the opportunity

More information

HHS PATH Intake Assessment

HHS PATH Intake Assessment HHS PATH Intake Assessment This form is to be used in assisting case managers, intake workers, and HMIS users to record client level program specific data elements for input into Servicepoint. Project:

More information

New Client Information Sheet

New Client Information Sheet New Client Information Sheet PSY Family Services Please complete ALL questions 301 W. Rosedale, Fort Worth, TX 76104 1. Client Demographics Patient Name: Last: First: Middle: Sex: ( )M ( )F DOB: Age: School

More information

FALL RIVER HOUSING AUTHORITY

FALL RIVER HOUSING AUTHORITY FALL RIVER HOUSING AUTHORITY Tenant Selection Office 220 Johnson Street Fall River, MA 02723 (508) 675-3519 www.fallriverha.org PRE-APPLICATION FOR FEDERAL PUBLIC HOUSING OFFICE USE ONLY: DATE: APP #:

More information

Policy Impact Assessment (including Equality Impact Assessment)

Policy Impact Assessment (including Equality Impact Assessment) Policy Impact Assessment (including Equality Impact Assessment) The purpose of conducting this Policy Impact Assessment is to ensure that the activities of the Force when delivering policy, strategy, function

More information

4b SAFER PRISONS: CELL SHARING RISK ASSESSMENT

4b SAFER PRISONS: CELL SHARING RISK ASSESSMENT 4b SAFER PRISONS: CELL SHARING RISK ASSESSMENT Cell Sharinq Risk Assessment Policy update 4.42 Paragraphs 6.21-6.38 of PW2 described the background to the introduction of PSI 26/2002 and the introduction

More information

COUNCIL TAX 2018/19. Berkshire, Buckinghamshire and Oxfordshire

COUNCIL TAX 2018/19. Berkshire, Buckinghamshire and Oxfordshire COUNCIL TAX 2018/19 Berkshire, Buckinghamshire and Oxfordshire PCC Foreword Over the last seven years the Thames Valley Police budget has reduced by 99m and a further 14.3m savings need to be made over

More information

Life Event Change (Retirees, Survivors & Inactive Plan Members)

Life Event Change (Retirees, Survivors & Inactive Plan Members) Life Event Change (Retirees, Survivors & Inactive Plan Members) Please print, complete, and mail, fax, or email this form to the Board of Pensions. Use this form to report life events (such as getting

More information

Mid Market Rent Application Form

Mid Market Rent Application Form About You Title First Name(s) Last Name Current Address Applicant Date Of Birth Daytime Number Mobile Number Email Address Preferred Contact Method How did you hear about MMR? Relationship to You Who else

More information

Report by the Local Government and Social Care Ombudsman

Report by the Local Government and Social Care Ombudsman Report by the Local Government and Social Care Ombudsman Investigation into a complaint against South Tyneside Metropolitan Borough Council (reference number: 16 005 776) 13 February 2018 Local Government

More information

NFA response to government consultation on social housing fraud

NFA response to government consultation on social housing fraud NFA response to government consultation on social housing fraud March 2012 Introduction The National Federation of ALMOs (NFA) represents 55 ALMOs which manage over 800,000 council homes across 54 local

More information

POSITIVE SOLUTIONS FAIR PROCESSING NOTICE

POSITIVE SOLUTIONS FAIR PROCESSING NOTICE FAIR PROCESSING NOTICE P 1 POSITIVE SOLUTIONS FAIR PROCESSING NOTICE INTRODUCTION following: Positive Solutions (Financial Services) Ltd. Registered Individuals of Positive Solutions (Financial Services)

More information

Fair Processing Notice

Fair Processing Notice Fair Processing Notice Mortgage Select SW Ltd ( Mortgage Select ) and our advisers and staff are committed to complying with the Data Protection Act 1998. As a financial services intermediary Mortgage

More information

What is a Fair Processing Notice (FPN)? To ensure that we process your personal data fairly and lawfully we are required to inform you:

What is a Fair Processing Notice (FPN)? To ensure that we process your personal data fairly and lawfully we are required to inform you: Fair Processing Notice Intrinsic Financial Services ("Intrinsic") it's Appointed Representatives ("AR") and the AR's Advisers are committed to complying with the Data Protection Act 1998. As a financial

More information

All subscribers of the Long Beach Unified School District s Self-Insured Health Plan

All subscribers of the Long Beach Unified School District s Self-Insured Health Plan BUSINESS DEPARTMENT Financial Services Risk Management Branch 1515 Hughes Way, Long Beach, CA 90810 MEMORANDUM TO: All subscribers of the Long Beach Unified School District s Self-Insured Health Plan From:

More information

ACCOUNTING FOR DISCLOSURES OF PROTECTED HEALTH INFORMATION

ACCOUNTING FOR DISCLOSURES OF PROTECTED HEALTH INFORMATION Children's Hospital and Regional Medical Center (Administrative Policy/Procedure: IM) ACCOUNTING FOR DISCLOSURES OF PROTECTED HEALTH INFORMATION POLICY: Children s supports the right of patients or their

More information

Give you this notice of our legal duties and privacy practices related to the use and disclosure of your protected health information

Give you this notice of our legal duties and privacy practices related to the use and disclosure of your protected health information Notice Of Privacy Practices - Effective Date: October 17, 2017 You may exercise the following rights by submitting a written request to the Student Health Center Privacy Contact (Director of Health Services).

More information

Application Reference: ATT. Position applied for: Section 1: Personal details. Address: Telephone Number: Mobile Number:

Application Reference: ATT. Position applied for: Section 1: Personal details.  Address: Telephone Number: Mobile Number: Application Reference: ATT Position applied for: Is the position: Full time: Part time: Permanent: Temporary: How did you find out about the post: (Please refer to any publication or website is relevant)

More information

Trinity Family Physicians

Trinity Family Physicians Trinity Family Physicians Consent and Authorization for Minors By law, a healthcare provider must attempt to contact a birth / custodial parent or legal guardian prior to rendering treatment to a minor

More information

VETTING AND BARRING SCHEME PHASING IN ARRANGEMENTS

VETTING AND BARRING SCHEME PHASING IN ARRANGEMENTS VETTING AND BARRING SCHEME PHASING IN ARRANGEMENTS Since January this year, the new Independent Safeguarding Authority (ISA) has been taking all barring decisions on new cases referred to it under the

More information

Saint Louis University Notice of Privacy Practices Effective Date: April 14, 2003 Amended: September 22, 2013

Saint Louis University Notice of Privacy Practices Effective Date: April 14, 2003 Amended: September 22, 2013 Saint Louis University Notice of Privacy Practices Effective Date: April 14, 2003 Amended: September 22, 2013 This notice describes how medical information about you may be used and disclosed and how you

More information

S A F E G UARDING W O R K S H O P : C H I L D H O P E

S A F E G UARDING W O R K S H O P : C H I L D H O P E S A F E G UARDING W O R K S H O P : C H I L D H O P E A I M S O F T H E C O U R S E Share the learning from UUK s safeguarding journey Prompt discussion about the challenges and opportunities other organisations

More information

PROCESS FOR RESPONDING TO PREVENT / EXTREMISM Freedom of Information Act REQUESTS

PROCESS FOR RESPONDING TO PREVENT / EXTREMISM Freedom of Information Act REQUESTS Publications Gateway Ref. No. 04364 PROCESS FOR RESPONDING TO PREVENT / EXTREMISM Freedom of Information Act REQUESTS Introduction 1. This document provides guidance for responding to Freedom of Information

More information

Upper Tribunal (Immigration and Asylum Chamber) DA/00257/2014 THE IMMIGRATION ACTS

Upper Tribunal (Immigration and Asylum Chamber) DA/00257/2014 THE IMMIGRATION ACTS Upper Tribunal (Immigration and Asylum Chamber) DA/00257/2014 THE IMMIGRATION ACTS Heard at: Field House Decision and Reasons Promulgated On 24 th November 2015 On 11 th December 2015 Before Upper Tribunal

More information

PROPERTY INFORMATION FORM. Plumlife (the Local HomeBuy Agent) as agent for Homes and Communities Agency (the Agency)

PROPERTY INFORMATION FORM. Plumlife (the Local HomeBuy Agent) as agent for Homes and Communities Agency (the Agency) PROPERTY INFORMATION FORM SCHEME: To: HELP TO BUY Plumlife (the Local HomeBuy Agent) as agent for Homes and Communities Agency (the Agency) PART 1 Named Applicant 1: Date of birth: Contact Telephone Number:

More information

Mary Holcomb, Psy.D., Licensed Psychologist 125 West Pineview Street, Ste Altamonte Springs, FL (407)

Mary Holcomb, Psy.D., Licensed Psychologist 125 West Pineview Street, Ste Altamonte Springs, FL (407) Mary Holcomb, Psy.D., Licensed Psychologist 125 West Pineview Street, Ste. 1005 Altamonte Springs, FL 32714 (407) 951-6920 ACKNOWLEDGEMENT OF NOTICE OF PSYCHOLOGISTS AND COUNSELORS POLICIES AND PRACTICES

More information

2003 American Medical Association All Rights Reserved

2003 American Medical Association All Rights Reserved Reproduction and use of this form by physicians and their staff is permitted. Any other use, duplication or distribution of this form by any other party requires the prior written approval of the American

More information

Connecticut Asthma & Allergy Center LLC Registration Form

Connecticut Asthma & Allergy Center LLC Registration Form Name: Connecticut Asthma & Allergy Center LLC Registration Form Last First Middle Initial Date of Birth: / / Sex: Race: Ethnicity: Language: SS#: xxx-xx- Address: # Street Apt/PO Box Email: Town State

More information

Hand & Microsurgery Medical Group, Inc. HIPAA NOTICE AND ACKNOWLEDGEMENT

Hand & Microsurgery Medical Group, Inc. HIPAA NOTICE AND ACKNOWLEDGEMENT Hand & Microsurgery Medical Group, Inc. HIPAA NOTICE AND ACKNOWLEDGEMENT Acknowledgement: I acknowledge that I have received the attached Notice of Privacy Practice. Patient or Personal Representative

More information

Circuit 17 Protocol for Preventive Family Preservation Services with Imminent Risk Cases

Circuit 17 Protocol for Preventive Family Preservation Services with Imminent Risk Cases Circuit 17 Protocol for Preventive Family Preservation Services with Imminent Risk Cases Florida Chapter 39 (Dependency Statute) clearly outlines the importance of prevention and early intervention services

More information

Pensions Table of contents

Pensions Table of contents Pensions Pensions Table of contents Purpose of guidance 2 Outline of provisions in the Police Pension Scheme 2 How the decision is made 3 Informing applicants 6 Appeals procedure 7 Consistency across forces

More information

39. PROTECTED HEALTH INFORMATION POLICY

39. PROTECTED HEALTH INFORMATION POLICY 39. PROTECTED HEALTH INFORMATION POLICY POLICY Scott County employs a "minimum necessary" standard that prohibits the use or disclosure of more than the minimum amount of protected health information (PHI)

More information

OREGON PUBLIC SAFETY SYSTEM SURVEY DOC Responses (N=4) April 2010

OREGON PUBLIC SAFETY SYSTEM SURVEY DOC Responses (N=4) April 2010 OREGON PUBLIC SAFETY SYSTEM SURVEY DOC Responses (N=) April 2010 Report by the Crime and Justice Institute at Community Resources for Justice INTRODUCTION Faced with implementing unprecedented reductions

More information

Tenancy Sustainment Statement

Tenancy Sustainment Statement Tenancy Sustainment Statement 1 Vision 2025 Strategic Plan 2016-2019 Radian s aim is for customer satisfaction and income collection to be sustained in top quartile performance whilst reducing costs and

More information

APPLICATION FOR TEACHING APPOINTMENT

APPLICATION FOR TEACHING APPOINTMENT APPLICATION FOR TEACHING APPOINTMENT This application form must be completed, but additional information may be attached. Please make sure you read any accompanying information before you complete this

More information

Ministry of Social Development Output Plan 2010/2011 Vote Social Development Vote Senior Citizens Vote Veterans' Affairs

Ministry of Social Development Output Plan 2010/2011 Vote Social Development Vote Senior Citizens Vote Veterans' Affairs Ministry of Social Development Output Plan Vote Social Development Vote Senior Citizens Vote Veterans' Affairs Social Development Vote Youth Development MINISTRY OF SOCIAL DEVELOPMENT Te Manat~ Whakahiata

More information

JUVENILE AND DOMESTIC RELATIONS DISTRICT COURT Earl J. Conklin, Director of Court Services. FY 2020 Proposed Budget - General Fund Expenditures

JUVENILE AND DOMESTIC RELATIONS DISTRICT COURT Earl J. Conklin, Director of Court Services. FY 2020 Proposed Budget - General Fund Expenditures Earl J. Conklin, Director of Court Services 1425 N. COURTHOUSE RD.,SUITE 5100, ARLINGTON, VA 22201 703-228-4600 jdrcourt@arlingtonva.us Our Mission: To provide effective, efficient and quality services,

More information

Lee County Central Point of Coordination

Lee County Central Point of Coordination Lee County Central Point of Coordination NOTICE OF PRIVACY PRACTICES Effective: April 14, 2003 THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS

More information

Name: Address: Telephone number: Social Security Number: Relationship to HOH

Name: Address: Telephone number: Social Security Number: Relationship to HOH Family Information Name: Address: Telephone number: Social Security Number: Primary language: Yes No Family Composition (circle all appropriate categories from the choices below)* Name (last, first) Date

More information

PROMISE HOME SERVICES, INC. D/B/A PROMISE CARE AT HOME NOTICE OF PRJV ACY PRACTICES

PROMISE HOME SERVICES, INC. D/B/A PROMISE CARE AT HOME NOTICE OF PRJV ACY PRACTICES PROMISE HOME SERVICES, INC. D/B/A PROMISE CARE AT HOME NOTICE OF PRJV ACY PRACTICES Effective: September 1, 2013 THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW

More information

Home Choice Application Form

Home Choice Application Form Home Choice Application Form Housing in rth Somerset Produced for rth Somerset Housing Team by CTPLD August 2016 1 Please fill in this form if you would like to put your name on the Housing Register. Answer

More information

NICOLAS WARNER, Psy.D.

NICOLAS WARNER, Psy.D. PLEASE PRINT LEGIBLY Client Information How Did You Hear About Dr. Warner? Full Client Name Home Phone Voice Message OK? YES NO Cell Phone Voice Message OK? YES NO Work Phone Voice Message OK? YES NO Preferred

More information

1. INTRODUCTION AND PURPOSE OF THIS DOCUMENT:

1. INTRODUCTION AND PURPOSE OF THIS DOCUMENT: NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. IT APPLIES TO TALLAHASSEE PRIMARY CARE ASSOCIATES,

More information

Revolutionising Global Student Travel Insurance

Revolutionising Global Student Travel Insurance Revolutionising Global Student Travel Insurance For international students studying in the United Kingdom HealthCare International s Global Student Travel Insurance An insurance policy for international

More information

Not Protectively Marked

Not Protectively Marked Attendance MINUTES OF THE POLICE AND CRIME COMMISSIONER S PERFORMANCE AND SCRUTINY GROUP WEDNESDAY, 9th MARCH 2016 POLICE MUTUAL, 20 CHAPEL STREET, LIVERPOOL at 2.00pm Office of the Police and Crime Commissioner

More information

UN Open Ended Working Group on Ageing United Kingdom policy contribution

UN Open Ended Working Group on Ageing United Kingdom policy contribution UN Open Ended Working Group on Ageing United Kingdom policy contribution Equality and non-discrimination 1) Does your country s constitution and/or legislation (a) guarantee equality explicitly for older

More information

EXPLANATORY MEMORANDUM TO THE SAFEGUARDING VULNERABLE GROUPS ACT 2006 (CONTROLLED ACTIVITY) (WALES) REGULATIONS 2010

EXPLANATORY MEMORANDUM TO THE SAFEGUARDING VULNERABLE GROUPS ACT 2006 (CONTROLLED ACTIVITY) (WALES) REGULATIONS 2010 EXPLANATORY MEMORANDUM TO THE SAFEGUARDING VULNERABLE GROUPS ACT 2006 (CONTROLLED ACTIVITY) (WALES) REGULATIONS 2010 This Explanatory Memorandum has been prepared by the Directorate for Children's Health

More information

NOT PROTECTIVELY MARKED. Report reference number PCC/000213

NOT PROTECTIVELY MARKED. Report reference number PCC/000213 Approved By: Charles Garbett, Acting Chief Executive and Treasurer (s151 officer) Classification of Paper: Not Protectively Marked Report to PCC Report reference number PCC/000213 Date of Decision Date

More information

YWCA of NIAGARA of the Niagara Frontier TRANSITIONAL HOUSING PROGRAM APPLICATION FOR RESIDENCY Low-income housing tax credit property

YWCA of NIAGARA of the Niagara Frontier TRANSITIONAL HOUSING PROGRAM APPLICATION FOR RESIDENCY Low-income housing tax credit property YWCA of NIAGARA of the Niagara Frontier TRANSITIONAL HOUSING PROGRAM APPLICATION FOR RESIDENCY Low-income housing tax credit property Carolyn s House 542 6 th St Niagara Falls NY 14301 716.278.9662 In

More information

Financial Assessment for Adoption Allowance Guidance for Adopters

Financial Assessment for Adoption Allowance Guidance for Adopters Financial Assessment for Adoption Allowance Guidance for Adopters 2 nd October 2015 Next Review date September 2016 Am I eligible to receive financial support? As an adopter, you will become eligible to

More information

ADULT SELF ASSESSMENT

ADULT SELF ASSESSMENT ADULT SELF ASSESSMENT In filling out this form you are welcome to provide as much information as you would like. If you find a question that you desire to leave blank, you are welcome to do so for any

More information

Pompton Lakes Board of Education Annual Health Plan Negotiated Employee Contribution Comparison Single Coverage - July 2018 through June 2019

Pompton Lakes Board of Education Annual Health Plan Negotiated Employee Contribution Comparison Single Coverage - July 2018 through June 2019 Single Coverage - July 2018 through June 2019 Annual Single Coverage Negotiated Contribution Step 2: Identify the below medical plan in Range that matches your chosen plan of benefits; add the prescription

More information

Christina Agustin, MD Board Certified in Adult Psychiatry 1 Lake Bellevue Drive, Suite 101 Bellevue, WA Phone Fax:

Christina Agustin, MD Board Certified in Adult Psychiatry 1 Lake Bellevue Drive, Suite 101 Bellevue, WA Phone Fax: Christina Agustin, MD Board Certified in Adult Psychiatry 1 Lake Bellevue Drive, Suite 101 Bellevue, WA 98005 Phone 425-301-9869 Fax: 866-546-1618 Welcome to my practice. I look forward to meeting with

More information

Therapy for Developmental Disabilities, LLC THERAPY FOR DEVELOPMENTAL DISABILITIES NOTICE OF PRIVACY PRACTICES. Effective: September 23, 2013

Therapy for Developmental Disabilities, LLC THERAPY FOR DEVELOPMENTAL DISABILITIES NOTICE OF PRIVACY PRACTICES. Effective: September 23, 2013 Therapy for Developmental Disabilities, LLC THERAPY FOR DEVELOPMENTAL DISABILITIES NOTICE OF PRIVACY PRACTICES Effective: September 23, 2013 THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY

More information

NOTICE OF PRIVACY PRACTICES

NOTICE OF PRIVACY PRACTICES NOTICE OF PRIVACY PRACTICES Effective as of September 23, 2013 THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW

More information

Linda Smoling Moore, Ph.D. Licensed Psychologist

Linda Smoling Moore, Ph.D. Licensed Psychologist Linda Smoling Moore, Ph.D. Licensed Psychologist 5601 River Road, Suite C-19 301-654-4320 Bethesda, Maryland 20816 Fax: 301-598-3947 PSYCHOTHERAPIST-PATIENT SERVICES AGREEMENT Welcome to my practice. This

More information

O F F E N D E R I N T E R V E N T I O N S H A R M R E D U C T I O N A N D P R E V E N T I O N I N C R I M I N A L J U S T I C E P R O V I S I O N S

O F F E N D E R I N T E R V E N T I O N S H A R M R E D U C T I O N A N D P R E V E N T I O N I N C R I M I N A L J U S T I C E P R O V I S I O N S O F F E N D E R I N T E R V E N T I O N S D Y F O D O L H A R M R E D U C T I O N A N D P R E V E N T I O N I N C R I M I N A L J U S T I C E P R O V I S I O N S WHAT IS DYFODOL / OFFENDER INTERVENTIONS?

More information

NOTICE OF PRIVACY PRACTICES

NOTICE OF PRIVACY PRACTICES NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. If you have any

More information

Notice of Privacy Practices Linn County Employee Health Care and Health Related Benefits Programs

Notice of Privacy Practices Linn County Employee Health Care and Health Related Benefits Programs Notice of Privacy Practices Linn County Employee Health Care and Health Related Benefits Programs THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS

More information

1. PERSONALIZED PRIMARY CARE Benefits and Services. The Program provides the following amenities ( Amenities ) to persons who sign up as Members:

1. PERSONALIZED PRIMARY CARE Benefits and Services. The Program provides the following amenities ( Amenities ) to persons who sign up as Members: MEMBERSHIP AGREEMENT This Membership Agreement (the Agreement ) specifies the terms and conditions under which you, the undersigned member ( Member ), will be enrolled with PERSONALIZED PRIMARY CARE program

More information

Walsall Council. The Walsall Crisis Support Scheme SECTIONS

Walsall Council. The Walsall Crisis Support Scheme SECTIONS Walsall Council The Walsall Crisis Support Scheme SECTIONS 1. Purpose 2. Considerations for an award 3. Crisis Awards 4. Claiming a Crisis Award 5. Forms of Crisis Award 6. Community Care Awards 7. Claiming

More information

PRIVACY NOTICE - GOLFERS/VOLUNTEERS/PLAYERS

PRIVACY NOTICE - GOLFERS/VOLUNTEERS/PLAYERS PRIVACY NOTICE - GOLFERS/VOLUNTEERS/PLAYERS What we need Scottish Golf will be a controller of the personal information that you provide to us in this form / through this website. Golfers/Competitors personal

More information

Northampton Sex Therapy Associates, LLC 40 Main Street, Suite 103, Florence MA PATIENT INTAKE FORM

Northampton Sex Therapy Associates, LLC 40 Main Street, Suite 103, Florence MA PATIENT INTAKE FORM PATIENT INTAKE FORM Patient Name Home Phone Street Address Cell Phone Mailing Address Work Phone City Email State Zip Code Date of Birth May I call you at the above numbers? Y or N May I leave a message

More information

TEXAS EAR, NOSE AND THROAT SPECIALISTS, L.L.P. NOTICE OF PRIVACY PRACTICES

TEXAS EAR, NOSE AND THROAT SPECIALISTS, L.L.P. NOTICE OF PRIVACY PRACTICES TEXAS EAR, NOSE AND THROAT SPECIALISTS, L.L.P. NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

More information

Continued on Next Page

Continued on Next Page Accredited by The Samaritan Institute Therapist: AGREEMENT FOR PAYMENT AND FINANCIAL RESPONSIBILITIES Care and Counseling is a non-profit pastoral counseling center. The standard fee for a 1 st evaluation

More information

Stanbridge Primary School SCHOOL TRIPS POLICY

Stanbridge Primary School SCHOOL TRIPS POLICY Stanbridge Primary School SCHOOL TRIPS POLICY Signed (Chair): Signed (Headteacher): Name: Mr A Pick Name: Mr A McGovern Date: 08/10/2018 Date: 08/10/2018 Ratified: by Finance Committee Next Review: Term

More information

NOTICE OF PRIVACY PRACTICES SOUTH DAYTON ACUTE CARE CONSULTANTS, INC.

NOTICE OF PRIVACY PRACTICES SOUTH DAYTON ACUTE CARE CONSULTANTS, INC. NOTICE OF PRIVACY PRACTICES SOUTH DAYTON ACUTE CARE CONSULTANTS, INC. THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE

More information

Overview of Department of Criminal Justice Funding for the Biennium PRESENTED AT THE HOUSE COMMITTEE ON CORRECTIONS

Overview of Department of Criminal Justice Funding for the Biennium PRESENTED AT THE HOUSE COMMITTEE ON CORRECTIONS Overview of Department of Criminal Justice Funding for the 2018-19 Biennium PRESENTED AT THE HOUSE COMMITTEE ON CORRECTIONS LEGISLATIVE BUDGET BOARD STAFF February 23, 2017 Department of Criminal Justice

More information

Chapter 15: Integrity Measures (i) Overview

Chapter 15: Integrity Measures (i) Overview Chapter 15: Integrity Measures (i) Overview Intent: Program Integrity Measures cover a broad range of services that focus on ensuring, to the extent possible, that Income Support clients receive benefits

More information

THE IMMIGRATION ACTS. Heard at : Birmingham Magistrates Court Determination Promulgated On : 5 November 2014 On : 11 November 2014.

THE IMMIGRATION ACTS. Heard at : Birmingham Magistrates Court Determination Promulgated On : 5 November 2014 On : 11 November 2014. Upper Tribunal (Immigration and Asylum Chamber) Appeal Number: DA/00581/2014 THE IMMIGRATION ACTS Heard at : Birmingham Magistrates Court Determination Promulgated On : 5 November 2014 On : 11 November

More information

Who referred you to us? Who shall we contact in case of emergency? Phone:

Who referred you to us? Who shall we contact in case of emergency? Phone: Client Information Sheet (Leslie Jensby -Wichita Counseling and Coaching Center) Client: Last Name: First Name: MI Street: City: State: Zip Home Phone: Cell Phone SSN# - - Birth Date: Age: Sex: M / F Work

More information

Andrew Weissman, Psy.D., P.C. Clinical Psychologist

Andrew Weissman, Psy.D., P.C. Clinical Psychologist Andrew Weissman, Psy.D., P.C. Clinical Psychologist 428 South Gilbert Rd #109 A Gilbert, AZ 85296 Phone: (480) 750-0022 Fax: 866-273-7138 New Client Information Referred By: Today s Date: I. Client Information

More information

Equity Loan Application Form

Equity Loan Application Form Equity Loan Application Form 2 Equity Loan Application Form Office use only Name of Equity Loan Scheme applied for Ref : PLEASE READ ALL ACCOMPANYING INFORMATION BEFORE COMPLETING THIS FORM. Your form

More information

PERSONAL ACCIDENT CLAIM FORM

PERSONAL ACCIDENT CLAIM FORM PERSONAL ACCIDENT CLAIM FORM Please complete this form ( including Access to Medical Records & Reports form ) in BLOCK CAPITALS and return it to Rightpath Claims as soon as possible with the following

More information

INVITATION TO TENDER PROVISION OF HOUSING RELATED SUPPORT SERVICES FOR VULNERABLE PEOPLE (REF: ASC0016)

INVITATION TO TENDER PROVISION OF HOUSING RELATED SUPPORT SERVICES FOR VULNERABLE PEOPLE (REF: ASC0016) Wards Affected: All Wards. ITEM 6 PROCUREMENT & COMMISSIONING 15 DECEMBER 2015 INVITATION TO TENDER PROVISION OF HOUSING RELATED SUPPORT SERVICES FOR VULNERABLE PEOPLE (REF: ASC0016) Responsible Cabinet

More information

Patrick A. Quigley, Ph.D., LSAC

Patrick A. Quigley, Ph.D., LSAC Psychologist Patrick A. Quigley, Ph.D., LSAC Addiction Counselor Thank you for considering my services. The material on this site will take you through the intake paperwork that you will need to bring

More information

Housing Assistance Application

Housing Assistance Application Housing Assistance Application Head of Household Information Date: Last Name First Name: Middle: Note: Names should be legal names only, not aliases or nicknames Suffix (circle one) II III IV Jr Sr None

More information

Notice of Privacy Practices

Notice of Privacy Practices Notice of Privacy Practices (HIPAA Form) Allergy, Asthma, and Immunology of North Texas, PA THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS

More information