Risk of Harm declaration
Declaration
*
The client and/or their Parent/Carer is at risk of harm because we are not receiving the required service at this time.
Client Name
*
First Name
Last Name
Parent/Carer Name:
First Name
Last Name
What is the concern?
*
What outcome are you hoping for, and how will this support the current concerns?
*
Everyone in the home over the age of 16 is fully vaccinated against COVID-19
*
Yes
No
Further notes (Optional)
Submit
Should be Empty: