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Risk Assessment
Risk Assessment Form
Duncan
2019-03-14T11:03:36+00:00
Client
*
Assessor
*
Date
*
DD slash MM slash YYYY
A. Suicide
History of any previous suicide attempts
*
Yes
No
Thoughts or plans which indicate a risk of suicide
*
Yes
No
Suffers from a major mental illness(especially depression or a 'psychotic illness')
*
Yes
No
An expression of concern (especially from a relative or carer) about the risk of suicide.
*
Yes
No
B. Offending
Any significant past history of violence
*
Yes
No
Current thoughts, plans or symptoms indicating a risk of violence
*
Yes
No
Current behaviour suggesting there is a risk of violence
*
Yes
No
An expression of others about the risk of violence
*
Yes
No
C. Health
Suffers from an injecting-related viral infection
*
Yes
No
Engages in high risk sexual behaviour
*
Yes
No
History of substance misuse, related seizures, DTs or Blackouts
*
Yes
No
Evidence or record of cognitive impairment
*
Yes
No
Has serious physical issues or unmet needs
*
Yes
No
D. Social
Currently homeless or living in unstable housing
*
Yes
No
Problems with childcare or social services
*
Yes
No
Regular criminal activity
*
Yes
No
Self neglect
*
Yes
No
Social isolation
*
Yes
No
E. Accidental Overdose
Regular injector
*
Yes
No
Chaotic injector (groin or neck)
*
Yes
No
History of DVTs
*
Yes
No
Current poly-substance use
*
Yes
No
Alcohol abuse or dependence
*
Yes
No
F. Treatment Issues
Recent abstinence
*
Yes
No
History of erratic engagement
*
Yes
No
Dual Diagnosis with CMHT
*
Yes
No
Detox Required - Alcohol
*
Yes
No
Detox Required - Drugs
*
Yes
No
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