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					                                                 T O O L             O F       D A N G E R O U S N E S S               A S S E S S M E N T
                     Application of the An Act respecting the protection of persons whose mental state presents a danger to themselves or to others (R.S.Q., Chapter P-38.001)

City                                             Province                 Postal code                                                     ACTIONS
Telephone (            )                         Date of birth (DD/MM/YY)
1 . T Y P E S O F DA N G E R
Suicide ❑             Homicide ❑             Self-mutilation ❑         Violence towards others ❑
                                                                                                              UNCOOPERATIVE                                         COOPERATIVE
2 . L E V E L S O F E M E RG E N C Y
Plan: Where/When/How                         ❑ Not defined                                    LOW
Means or victim                              ❑ Not accessible
                                                                                                                     No danger                                         No danger
Plan: Where/When/How                         ❑ Partially defined
Means or victim                              ❑ Not chosen or not accessible                              The law does not apply                            The law does not apply
Threat of acting out after 48 hours          ❑ Definite plan
                                                                                                         • Give the person the name                        • Continue the intervention
Where?                                                 When?                                               and address of support                          • Refer as needed
How?                                                                                                       resources
                                                                                        AVERAGE          • Do follow-up
Access to means
Plan : Where/When/How                        ❑ Plan defined
Means                                        ❑ Plan chosen or accessible
Threat of acting out within 24 to 48 hours
Where?                                                 When?
                                                                                                                   Serious and                                       Serious and
How?                                                                                                          non-immediate danger                              non-immediate danger
Access to means                                                                                          Suggest or start a process for a                  No application of the law
                                                                                                         petition to the Court of
3 . FAC TO RS TO B E C O N S I D E R E D I N Q UA L I F Y I N G                                          Québec to obtain temporary                        • Continue the intervention
    THE ASSESSMENT                                                                                       confinement                                       • Ensure that the person is
History of similar violence                                    Yes ❑      No ❑         Don't know ❑                                                          taken charge of over the
Non-supportive network                                         Yes ❑      No ❑         Don't know ❑      • If it does not apply, try to                      short term
Consumption of alcohol and drugs                               Yes ❑      No ❑         Don't know ❑        maintain contact
Stopping usual activities                                      Yes ❑      No ❑         Don't know ❑
Deteriorated condition of premises                             Yes ❑      No ❑         Don't know ❑
Difficulty sleeping and eating                                 Yes ❑      No ❑         Don't know ❑
Stopping medication                                            Yes ❑      No ❑         Don't know ❑
Taking non-prescribed medication                               Yes ❑      No ❑         Don't know ❑      Serious and immediate danger                       Serious and immediate danger
Irregularity in taking psychotropic drugs                      Yes ❑      No ❑         Don't know ❑
Previous suicide attempt                                       Yes ❑      No ❑         Don't know ❑      Application of the law and use of                 No application of the law
Ability to control himself (self assessment by the person)     Yes ❑      No ❑         Don't know ❑      police officers for transportation
Network: Is there a person involved and accessible? If so,                                               to the hospital                                   • Hospital or crisis lodging
Name of family                                                 Telephone (      )                                                                            takes charge
or close friend                                                                                                                                            • Accompaniment until charge
Name of social                                                 Telephone (      )                                                                            is taken
Have these people been informed of the situation?        Yes ❑ No ❑
Triggering factors
factors                                                                                                Extract from the tool of assessing the dangerousness and evaluating the emergency
Time devoted
                             ______________h Person who cooperates        Yes ❑        No ❑
                                                                                                       (January 2001)developed in partnership with : Centre de crise Le Transit, Suicide-Action
to this intervention                                                                                   Montréal, Urgence psychosociale-justice du CLSC des Faubourgs and Centre de psychiatrie légale
Authorization document for transmission of this information                                            de l'Institut Philippe Pinel de Montréal. Adaptation by the partenaires de Laval.  April 2005
Signature of the person:
Signature of the referring agent: