Mental Health Risk Assessment Form

• Conducted on

  Date

• Patient Name

• Date of Birth

  Date

• Prepared by

SELF-HARM/SUICIDE

• Does the patient have a history of hurting themselves?

  No

  Yes

  N/A

• Does the patient's family have a history of suicide or self-harm?

  No

  Yes

  N/A

• Is the patient in a low mood?

  No

  Yes

  N/A

• Has the patient hinted on suicidal ideation?

  No

  Yes

  N/A

• Has the patient experienced any recent adverse life events?

  No

  Yes

  N/A

• Is the patient in a high level of distress?

  No

  Yes

  N/A

• Is the patient suffering from a physical illness or disability?

  No

  Yes

  N/A

• Does the patient live alone? (Or will live alone after discharge?)

  No

  Yes

  N/A

• Has the patient been feeling isolated from society?

  No

  Yes

  N/A

• Was the patient recently discharged from a hospital/prison?

  No

  Yes

  N/A

• Did the patient's significant other express any concerns about them?

  No

  Yes

  N/A

• Does the patient have a criminal record?

  No

  Yes

  N/A

• List all of the offences here.

• Any other observations related to self-harm.

CURRENT STATUS

• Is the patient demonstrating any hostile or threatening behavior?

  No

  Yes

  N/A

• Has the patient expressed any violent thoughts or fantasies?

  No

  Yes

  N/A

• Does the patient have problems controlling their temper?

  No

  Yes

  N/A

• Does the patient possess weapons with possible intent to use?

  No

  Yes

  N/A

• Is there a current risk of violence from the patient?

  No

  Yes

  N/A

• Does the patient have access to a potential or threatened victim?

  No

  Yes

  N/A

• Has the patient expressed ongoing drug or alcohol misuse?

  No

  Yes

  N/A

• Have others expressed concern about potential violence from the patient?

  No

  Yes

  N/A

• Any other observations related to the patient's current status.

HISTORY

• Does the patient have a history of violence?

  No

  Yes

  N/A

• Does the patient have a history of disengagement from services? (the patient has previously "dropped out" of a mental health care program)

  No

  Yes

  N/A

• Has the patient witnessed violence and/or emotional abuse in childhood?

  No

  Yes

  N/A

• Has the patient experienced violence and/or emotional abuse in childhood?

  No

  Yes

  N/A

• Does the patient have a history of deliberate or accidental fire setting?

  No

  Yes

  N/A

• Does the patient have a history of deliberately harming other people?

  No

  Yes

  N/A

• Does the patient have a history of deliberately harming children?

  No

  Yes

  N/A

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

SERIOUS SELF-NEGLECT

• Is the patient currently homeless?

  No

  Yes

  N/A

• Is the patient currently subject to unacceptable living conditions (e.g. hazards)?

  No

  Yes

  N/A

• Is the patient socially isolated? (e.g. refuses to talk to friends and family or has none)

  No

  Yes

  N/A

• Is the patient dehydrated?

  No

  Yes

  N/A

• Is the patient malnourished?

  No

  Yes

  N/A

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

  No

  Yes

  N/A

• 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)

  No

  Yes

  N/A

• Does the patient have any untreated physical health needs?

  No

  Yes

  N/A

• Does the patient have a history of persistent non-compliance with prescribed medication?

  No

  Yes

  N/A

• Does the patient have a history of alcohol abuse?

  No

  Yes

  N/A

• Does the patient have a history of substance abuse?

  No

  Yes

  N/A

• Any other observations.

EXPLOITATION/VULNERABILITY

• Is the patient currently, or was previously at risk of physical abuse?

  No

  Yes

  N/A

• Is the patient currently, or was previously at risk of sexual abuse?

  No

  Yes

  N/A

• Is the patient currently, or was previously at risk of social abuse?

  No

  Yes

  N/A

• Is the patient currently, or was previously at risk of emotional abuse?

  No

  Yes

  N/A

• Is the patient currently, or was previously at risk of financial abuse?

  No

  Yes

  N/A

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

  No

  Yes

  N/A

• Is the patient displaying symptoms of disinhibition?

  No

  Yes

  N/A

• Is the patient displaying symptoms of impulsiveness?

  No

  Yes

  N/A

• Is the patient displaying precocious behavior?

  No

  Yes

  N/A

• Is the patient living in unacceptable home conditions (e.g. hazards)?

  No

  Yes

  N/A

• 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

• Health professional signature

  Sign