Mental Health Risk Assessment Form

• Conducted on

  Date

• Client Name

• Date of Birth

  Date

SELF-HARM/SUICIDE

• Do you have a history of hurting yourself?

  No

  Yes

• Does your family have a history of suicide or self-harm?

  No

  Yes

• Are you always in a low mood?

  No

  Yes

• Have you experienced any recent adverse life events?

  No

  Yes

• Are you in a high level of distress?

  No

  Yes

• Are you suffering from a physical illness or disability?

  No

  Yes

• Do you live alone? (Or will live alone after production?)

  No

  Yes

• Have you been feeling isolated from society?

  No

  Yes

• Are you recently discharged from a hospital/prison?

  No

  Yes

• Do your significant other express any concerns about you?

  No

  Yes

• Do you have a criminal record?

  No

  Yes

• List all of the offences here.

• Yes

  No

  N/A

• Any other observations related to self-harm.

CURRENT STATUS

• Have you noticed yourself demonstrating any hostile or threatening behaviour?

  No

  Yes

• Have you in recent times expressed any violent thoughts or fantasies?

  No

  Yes

• Do you have problems controlling your temper?

  No

  Yes

• Do you usually possess weapons with possible intent to use for self-defense?

  No

  Yes

• Is there a current risk of violence?

  No

  Yes

• Do you have access to a potential or threatened violence?

  No

  Yes

• Have you expressed ongoing drug or alcohol misuse?

  No

  Yes

HISTORY

• Do you have a history of disengagement from services?

  No

  Yes

• Have you witnessed violence and/or emotional abuse in childhood?

  No

  Yes

• Have you experienced violence and/or emotional abuse in childhood?

  No

  Yes

• Do you have a history of deliberate or accidental fire setting?

  No

  Yes

• Do you have a history of deliberately harming other people?

  No

  Yes

• Do you have a history of deliberately harming children?

  No

  Yes

• Any other observations related to the patient's history.

SERIOUS SELF-NEGLECT

• Are you currently homeless?

  No

  Yes

• Are you currently subject to unacceptable living conditions (e.g. hazards)?

  No

  Yes

• Are you socially isolated? (e.g. refuses to talk to friends and family or has none)

  No

  Yes

• Do you have poor hygiene? (e.g. has verbally expressed poor hygienic practices or evident in appearance and scent)

  No

  Yes

• Do you risk causing accidents for yourself or others due to negligence/apathy? (e.g. does not follow traffic lights, crosses the street with no regard for ongoing traffic)

  No

  Yes

• Do you have any untreated physical health needs?

  No

  Yes

• Do you have a history of persistent non-compliance with prescribed medication?

  No

  Yes

• Do you have a history of alcohol abuse?

  No

  Yes

• Do you have a history of substance abuse?

  No

  Yes

• Any other observations.

EXPLOITATION/VULNERABILITY

• Are you currently, or was previously at risk of physical abuse?

  No

  Yes

• Are you currently, or was previously at risk of sexual abuse?

  No

  Yes

• Are you currently, or was previously at risk of social abuse?

  No

  Yes

• Are you currently, or was previously at risk of emotional abuse?

  No

  Yes

• Are you currently, or was previously at risk of financial abuse?

  No

  Yes

• Are there threats against your privacy and dignity (past and/or present)?

  No

  Yes

• Are you displaying symptoms of disinhibition?

  No

  Yes

• Are you displaying symptoms of impulsiveness?

  No

  Yes

• Are you displaying precocious behavior?

  No

  Yes

• Are you living in unacceptable home conditions (e.g. hazards)?

  No

  Yes

• Any other observations.

SUMMARY RISK ASSESSMENT

• Overall likelihood to cause self-harm/ harm to others

  Extreme

  High

  Moderate

  Low

• Severity of self-harm/ harm to others

  Fatality

  Serious Injury

  Emotional Distress

  Minor

• Overall risk rating

  High

  Medium

  Low

• Summary findings on degree of risk and recommendations

• Date and time of approval

  Date

• Approver's signature

  Sign