The New Connection Risk Assessment form by HC121108044112

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									                              CHS Risk Assessment form
        This form helps us gather information about your situation in order that we can provide you
        with the appropriate levels of support whether that is within Coastline Homeless Service or
                                     through referrals to other agencies.

Name
Date of birth
Date of referral

Completed by                           Client                    Referrer
(please circle)
If referrer:
Name
Agency
Contact number

       Please circle yes or no. If you have circled yes then please provide as much information as
       possible.

       PHYSICAL HEALTH ISSUES
Do you have any physical health conditions or                           Yes                 No
disabilities?
If yes, could you please state what the condition(s)
is/are and how this affects you




Are you currently prescribed medicine for these                         Yes                 No
issues?
If yes, what?




Are you working with any other people or agencies                      Yes                 No
about this?
Who are they and what are their contact details?




Any other comments/information?
       MENTAL HEALTH ISSUES
Do you have any mental health conditions or              Yes    No
concerns?
If yes, please state what this condition(s) is/are and
how this affects you



If yes, are you currently prescribed medicine or self-   Yes    No
prescribe for these issues?
If yes, what?




Are you working with any other people or agencies        Yes    No
about your mental health issues?
If yes, who are they and what are their contact
details?




Any other comments/information?




       SUBSTANCE MISUSE

Have you ever used illegal drugs or misused              Yes    No
alcohol, medicine or legal highs or solvents?


Has this ever caused you problems (e.g. physical,
mental, criminal, financial, emotional or personal)      Yes    No
If yes, please describe




Are you currently using illegal drugs or misusing         Yes    No
alcohol, medicine or legal highs or solvents?

Have you ever injected drugs?                             Yes    No

If yes, are you currently injecting?                     Yes    No

If yes, when was the last time you had blood tests
done?
Have you ever overdosed or been chronically
intoxicated due to substance misuse?
If yes, when was this and what happened?

                                                      Yes     No


Have you ever or are you currently working with any     Yes        No
agencies who support you regarding your substance
use?
If yes, please provide information



                                                        Yes        No
Are you currently prescribed relating to your
substance misuse?

If yes, please provide information




       RISK TO SELF, OTHERS AND PROPERTY
RISK TO OTHERS AND PROPERTY

Do you have a history of:                               Yes        No

Violence to others                                      Yes        No

Violence caused by substance misuse                     Yes        No

Violence to staff members                               Yes        No

Paranoid thoughts or delusions relating to others       Yes        No

Criminal Record                                         Yes        No

Probation involvement                                   Yes        No

Prone to conflict                                       Yes        No

History of damage to property                           Yes        No

Thoughts or threats to damage property                  Yes        No

Offences relating to arson or criminal damage

If you have answered yes to any of the above
questions then please give further information
RISK TO SELF

Current or historical:
                                                              Yes                 No
History of neglect
                                                                Yes                 No
Reliance on others regarding hygiene, safety or
financial matters
                                                               Yes                 No
Risk from others
                                                               Yes                 No
Placing self in risky situations
                                                              Yes                 No
Suicidal thoughts
                                                               Yes                 No
Suicidal attempts
                                                              Yes                 No
Current self-harm
                                                               Yes                 No
Previous self-harm

If you have answered yes to any of these questions then please give further information




Any other comments or information?




       Signed ___________________________________________


       Dated ____________________________________________

								
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