Diaconia Intake Form

* meħtieġa/required

Note for Entity Representative:

Explain the purpose of collecting this information and ensure the client that their data privacy and confidentiality will be respected.
Explain that this data is being retained for the duration of the service being offered by the Archdiocese of Malta and five (5) years after the last point of contact according to Maltese legislation and professional practice.

Form

Date*

Entity name*

Reppresentative – Name*

Reppresentative – Surname*

Section 1: Client Personal Information

Client – Name*

Document*

I.D. number

Passport

Client I.D. card number*

Client Passport number*

Date of Birth*

Gender*

Address – House name/Door number*

Address – Road*

Locality*

Post Code

Mobile number*

Country Phone Number

Fixed line

Country Phone Number

Section 2: Referral Information

Referred by (if applicable)

Referring agency (if applicable)

Contact information (if applicable)

Client is receiving the support of a social worker

Yes

Social worker – Name*

Social worker – Surname*

Social worker – Agency*

Sovial worker mobile*

Country Phone Number

Section 3: Demographic Information

Client status*

Preferred language for communication*

Section 4: Presenting issues

Give a short description of the presenting issue highlighting the predominant challenges the person faces at a psychological, social and economic level.
List any relevant information that may benefit the care offered by the Archdiocese of Malta.

Short Description

Section 4: Privacy and consent

Terms and conditions*

In this declaration:
• ‘Archdiocese’ or ‘Church’ refers to the Archdiocese of Malta meaning the Catholic Church in Malta;
• Parish refers to the parish/church/centre/community where the programme is being held;
• Parish Priest refers to any priest or religious person or any lay person responsible for the services offered as part of the Djakonija Commission of the Parish;
• DPC refers to the Data Protection Coordinator for Parishes. ([email protected]);
• ‘Legislation’ refers to the ‘Data Protection Act (Cap. 586 of the Laws of Malta’, to the General Data Protection Regulation (EU) 2016/679 (GDPR) and any other legislation or regulation in due force.

I the undersigned declare that:
• I am aware that this information is being collected on behalf of the Archdiocese of Malta and that this same information will be held and processed as defined in the General Terms and Conditions for Personal Data Protection in Parishes (hereinafter referred to as Terms and Conditions), according to the applicable ecclesial and state laws. This information shall be processed by various entities/sections of the Archdiocese related to services offered by the parish Djakonija Commission. For further information on withdrawal of consent given in this form, access, retention, processing, portability, correction, objection, deletion of data and the right to initiate a complaint with the supervisory authority I can access these Terms and Conditions on the Archdiocese website (www.church.mt). We can approach the Parish Priest for further information or to exert these rights.
• I am aware that this information is being retained and processed for purposes related to djakonija services offered by the parish. I am aware that certain correspondence related to the services offered to me and my family shall be kept for pastoral and administrative purposes.
• I know that parish buildings may be equipped with security cameras (CCTV) and that these records are kept as stipulated in the Terms and Conditions in line with state law.
• I know that this information can be forwarded to other entities (which are not included in article 1.4 of these Terms and Conditions) for purposes to receive a better service. Yes/No
• I declare that all information given in this application is correct and should there be any changes I bind myself to immediately inform the Parish Djakonija Commission. Yes/No
• I give access to Parish Representatives to have access to my personal contact details to be used to communicate with me by means of messages (sms or similar) / e-mails/correspondence related to the services I am to receive. Yes/No
• I agree that this information may be used to update the Parish database for pastoral purposes, as stipulated in the Terms and Conditions. Yes/No (without prejudice to other given consents)
• I wish to receive further information with regards to various Parish activities. Yes/No (without prejudice to other given consents)

• I am aware that before signing this document I am free to contact the Parish Priest or the concerned DPC ([email protected]) for any queries or clarifications.
• I understand that I have the right to retain any information or withdraw any consent given in this form in which case the Church has the right to restrain or terminate any services offered to me.
• I declare that I have been given the opportunity to read the Terms and Conditions before signing this declaration.

I agree with the terms and conditions