Risk Assessment. Person Demographic Information. Record the date of admission.
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1 Risk Assessment The following assessment tool is to be used if the person served has made contact with a behavioral health professional and is willing to work with us, to some degree to assess risk. If a person is fully determined to take their own life or that of another, there may be nothing a behavioral health professional can do to prevent this from occurring. The assessment of risk is complicated and is based on many interacting factors. The items in this tool are based on research and many years of practical experience. The tool is a means to gather data. This data must then be considered in its entirety before making a determination of risk. Person s Name Record Number of Admission Organization/Program Name DOB Gender Safety and Protective Factors Stable Housing Stable Employment Has Income/Insurance/ Benefits Has Positive Alliance with Service Providers Experience Positive Benefits from Treatment Seeks Assistance When at Risk/in Danger Had Developed a Crisis/Safety Plan/ WRAP Plan/ Self Care Plan Medication Adherence Able to Plan and Follow Through Capacity for Empathy/Perspective Taking Religious/ Spiritual Beliefs or Involvement Stable/Positive Personal Relationships Person Demographic Information Record person s first, last name and middle initial. Order of name is at agency discretion. Record agency s established identification number for the child served. Record the date of admission. Record the organization/program for whom you are delivering the service. Record the person s date of birth. Indicate person s gender by checking the appropriate box. If checking Transgender box, also complete box of current gender designation for insurance purposes. Safety and Protective Factors These factors often support individuals with self-management of risk issues. Many of these factors are found elsewhere in the assessment but repeated here for ease of formulating concerns about risk. Indicate below by checking yes, no, or not known if the person is currently engaged with any Safety and Protective Activities. Comment on each yes answer. 77
2 Positive Family Supports/ Has Children or Pets Has Insight About Her/ His Symptoms Sobriety/ No Active Substance Use Low Psychosocial Stressors Capacity to Weigh Risks and Benefits of Decisions Capacity for Emotional Self-Regulation Capacity for Self- Management of Behaviors Future Orientation/ Goals Recovery Orientation Harm to Others Factors Thoughts/ Plans for Harming/ Killing Others Direct Violent Thoughts Indirect Threats Implying Violence Verbal Aggression that Precedes Violence Serious Property Damage Physical Assault/ Violence to Others Sexual Assault Against Others Illegal or Antisocial Behaviors/ Arrest/ Conviction/ NGRI/ Incarceration Neglect or Abuse of Dependents Stalking/ Restraining Order/ Obsession Targeted at a Particular Person Risk Factors Indicate below if the person has any past or current risk factors relating to the category. For each item marked past or current, please not the context of the risk factor and any other relevant information regarding its occurrence. If there is current presentation of an acute risk, such as suicidal ideation, homicidal ideation, etc., please refer to agency specific protocols. 78
3 Arson/ Fire Setting/ Fire Safety Issues Extreme Paranoia/ Perception of Threats/ Command Hallucinations to Harm Others Failure of Prior External Supervision to Control or Reduce Harm to Others Other Harm or Danger to Others Issues Other Harm or Danger to Others Issues Suicidal Thoughts/ Plans/ Rehearsal Behaviors Suicide attempts Self-Harm Behaviors Family History of Suicidal/ Self-Harm Life Threatening Eating Disorder Victimized by Others/ Places Self in Danger Command Hallucinations for Self-Harm Elopement Without Ability to Self-Preserve Self-Harm Factors Other Risk Factors These factors may increase the level of concern a clinician has regarding potential risk. Recent Significant Loss Memory Impairment/ Dementia/ Disorientation Developmental Disability/ PDD Spectrum Young Age at Time of First Violent Behavior Early Attachment Issues Traumatic Brain Injury 79
4 Cognitive Impairment/ Learning Disability Extreme Impulsivity Presents with Trauma Related Symptoms Lack of Empathy/ Remorse When Aggressive Injury to Animals Positive View of Criminal Behavior Requires Substitute Decision Making Access to/ Keeping/ Carrying/ Using Weapons Non-Violent Problematic Sexual Behavior Person is Actively Abusing Substances Increased Risk Associated with Presence of Psychiatric Symptoms Unwilling/ Unable to Engage in Shared Risk Decisions/ Risk Reduction Efforts Chronic Medical Illness or Chronic Pain Unable/ Unwilling to Manage Risks Experiencing Acute High Stress Situation Summarize the Risk and Protective Factors and Indicate if Further Planning is Needed per Agency Protocols Person s Signature (Optional, if clinically appropriate) Summarize the Risk and Protective Factors Signatures Signature of the person to be served by the agency indicating his/her understanding and acceptance of the treatment recommendation/assessed needs. 80
5 Parent/ Guardian Signature (if appropriate) Clinician/ Provider- Print Name/ Credential Supervisor- Print Name/ Credential (if needed) Clinician/ Provider Signature Supervisor Signature (if needed) Psychiatrist/MD/DO (if required) Legibly print name and credential(s) of person completing the Comprehensive Assessment. If the diagnosis is rendered by a clinician other than the clinician printed above, then the clinician rendering the diagnosis must print his/her educational level and highest license level. Legible signature of person completing the Comprehensive Assessment. If the diagnosis is rendered by a clinician other than the clinician signed above, then the clinician rendering the diagnosis must provide his/her signature and record his/her educational level and highest license level. This is a requirement for Opiate Treatment Programs. 81
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