INITIAL ASSESSMENT & SUPPORT ELIGIBILITY REVIEW
Please answer ALL QUESTIONS in BLOCK CAPITALS. Incomplete responses may delay or prevent access to support.
CASE REFERENCE: MARIANNE STRANGREFERRAL SOURCE: SELF
PART 001: PERSON REFERRED
PART 002: SAFETY DECLARATION
This section is reproduced from Marianne’s fictional assessment record. It is not a clinical assessment tool.
Are you, or is anyone close to you, currently at immediate risk of harm?
□ YES — FOLLOW URGENT CARE PATH □ NO — CONTINUE □ NOT SURE □ PERSON DECLINED TO ANSWER
If this question feels personally relevant, do not use this fictional form. View real support information.
PART 003: TESTING PROTOCOL
Draw the bird you associate most closely with loneliness. There are no incorrect responses. Your drawing may inform assessment, eligibility and onward referral.
PART 004: OUTCOMES (FOR OFFICIAL USE ONLY)
□ ELIGIBLE □ INELIGIBLE ☒ FURTHER TESTING REQUIRED
By signing below, you confirm that the outcome has been explained to you. Your signature does not indicate agreement.