Title Page

  • Site conducted

  • Conducted on

  • Client Name

  • Date of Birth

  • Prepared by

SELF-HARM/SUICIDE

  • Does the patient have a history of hurting themselves?

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

  • Is the patient in a low mood?

  • Has the patient hinted on suicidal ideation?

  • Has the patient experienced any recent adverse life events?

  • Is the patient in a high level of distress?

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

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

  • Has the patient been feeling isolated from society?

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

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

  • Does the patient have a criminal record?

  • List all of the offences here.

  • Any other observations related to self-harm.

  • Please detail any support plans (in place or being developed) to manage identified risks

CURRENT STATUS

  • Is the patient demonstrating any hostile or threatening behavior?

  • Has the patient expressed any violent thoughts or fantasies?

  • Does the patient have problems controlling their temper?

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

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

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

  • Has the patient expressed ongoing drug or alcohol misuse?

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

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

  • Please detail any support plans (in place or being developed) to manage identified risks

HISTORY

  • Does the patient have a history of violence?

  • Does the patient have a history of disengagement from services? (the patient has previously "dropped out" of NDIS services)

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

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

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

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

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

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

  • Please detail any support plans (in place or being developed) to manage identified risks

SERIOUS SELF-NEGLECT

  • Is the patient currently homeless?

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

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

  • Is the patient dehydrated?

  • Is the patient malnourished?

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

  • 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)

  • Does the patient have any untreated physical health needs?

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

  • Does the patient have a history of alcohol abuse?

  • Does the patient have a history of substance abuse?

  • Any other observations.

  • Please detail any support plans (in place or being developed) to manage identified risks

EXPLOITATION/VULNERABILITY

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

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

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

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

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

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

  • Is the patient displaying symptoms of disinhibition?

  • Is the patient displaying symptoms of impulsiveness?

  • Is the patient displaying precocious behavior?

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

  • Any other observations.

  • Please detail any support plans (in place or being developed) to manage identified risks

SUMMARY RISK ASSESSMENT

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

  • Severity of self-harm/ harm to others

  • Overall risk rating

  • Summary findings on degree of risk and recommendations

  • Signature of person completing

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