Risk Assessment Form - Gloucester House

Risk Assessment FormDuncan2019-03-14T11:03:36+00:00

Client*
Assessor*
Date*
Date Format: 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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Risk Assessment