Risk Screening Tool Print

							Client Name_________________________ Completed by ________________
DOB        ___________________       Support Worker ________________
Date       ___________________

Reason for Risk Screening
Booking In/Referral    Change of Circumstances            Quarterly Review     

Risk to Self                      Yes No       N/K   Mental Health Issues               Yes   No

Previous Suicide Attempts                            Self Managing Medication                  

Expressing suicidal ideas                            Medication side effects

Has Suicide Plan                                     Relationship problems

Self Injurious Behaviour                             Changes in behaviour

Neglect indicators                                   Delusional ideas
Personal Care
                                                     Withdrawal from services
Isolation
                                                     Hospitalisation
Abuse by Others
                                                     Anti Social Behaviour
Risk to others
Previous Violent Behaviour                           Distressing Hallucinations

Expressing intent to harm
                                                     Substance Use Issues
Paranoid Ideas
                                                     Alcohol Misuse
Impulsive
                                                     Changing patterns of
Sexually Inappropriate                               Misuse
Behaviour/Offences/registration
                                                     Detox / Rehab
Physical Health
                                                     Dangerous or risky
Prior tenancy difficulties                        misuse


                                           Actions
Is Risk Management Form needed           Yes           No


Is Action required today?               Yes            No