Title Page
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Conducted on
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Patient Name
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Date of Birth
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Prepared by
SELF-HARM/SUICIDE
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Does the patient have a history of hurting themselves?
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Does the patient's family have a history of suicide or self-harm?
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Is the patient in a low mood?
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Has the patient hinted on suicidal ideation?
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Has the patient experienced any recent adverse life events?
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Is the patient in a high level of distress?
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Is the patient suffering from a physical illness or disability?
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Does the patient live alone? (Or will live alone after discharge?)
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Has the patient been feeling isolated from society?
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Was the patient recently discharged from a hospital/prison?
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Did the patient's significant other express any concerns about them?
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Does the patient have a criminal record?
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List all of the offences here.
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Any other observations related to self-harm.
CURRENT STATUS
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Is the patient demonstrating any hostile or threatening behavior?
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Has the patient expressed any violent thoughts or fantasies?
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Does the patient have problems controlling their temper?
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Does the patient possess weapons with possible intent to use?
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Is there a current risk of violence from the patient?
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Does the patient have access to a potential or threatened victim?
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Has the patient expressed ongoing drug or alcohol misuse?
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Have others expressed concern about potential violence from the patient?
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Any other observations related to the patient's current status.
HISTORY
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Does the patient have a history of violence?
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Does the patient have a history of disengagement from services? (the patient has previously "dropped out" of a mental health care program)
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Has the patient witnessed violence and/or emotional abuse in childhood?
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Has the patient experienced violence and/or emotional abuse in childhood?
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Does the patient have a history of deliberate or accidental fire setting?
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Does the patient have a history of deliberately harming other people?
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Does the patient have a history of deliberately harming children?
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Any other observations related to the patient's history.
SERIOUS SELF-NEGLECT
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Is the patient currently homeless?
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Is the patient currently subject to unacceptable living conditions (e.g. hazards)?
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Is the patient socially isolated? (e.g. refuses to talk to friends and family or has none)
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Is the patient dehydrated?
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Is the patient malnourished?
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Does the patient have poor hygiene? (e.g. has verbally expressed poor hygienic practices or evident in appearance and scent)
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Does the patient risk causing accidents for themselves or others due to negligence/apathy? (e.g. does not follow traffic lights, crosses the street with no regard for ongoing traffic)
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Does the patient have any untreated physical health needs?
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Does the patient have a history of persistent non-compliance with prescribed medication?
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Does the patient have a history of alcohol abuse?
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Does the patient have a history of substance abuse?
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Any other observations.
EXPLOITATION/VULNERABILITY
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Is the patient currently, or was previously at risk of physical abuse?
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Is the patient currently, or was previously at risk of sexual abuse?
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Is the patient currently, or was previously at risk of social abuse?
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Is the patient currently, or was previously at risk of emotional abuse?
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Is the patient currently, or was previously at risk of financial abuse?
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Are there threats against the patients privacy and dignity (past and/or present)?
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Is the patient displaying symptoms of disinhibition?
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Is the patient displaying symptoms of impulsiveness?
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Is the patient displaying precocious behavior?
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Is the patient living in unacceptable home conditions (e.g. hazards)?
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Any other observations.
SUMMARY RISK ASSESSMENT
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Overall likelihood to cause self-harm/ harm to others
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Severity of self-harm/ harm to others
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Overall risk rating
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Summary findings on degree of risk and recommendations
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Health professional signature