Cross Care Intake & Risk Assessment

Cross Care

Intake & Risk Assessment
This risk assessment tool is to be used in identifying safety risks for staff when providing services to participants and is intended to highlight any risks when first engaging with a participant. The risks/hazards included in this template are not an exhaustive list. Your completed risk assessment should reflect all potential hazards to meet your requirements. Where risks have been identified associated to the psychosocial needs or complex behaviour needs of a participant a more specialised risk assessment may be required
Client's Name*
Name of referrer if not client
Relation and contact number of referrer
Client's Date of Birth

MonthDayYear
Date
Client's NDIS Number
Client's Address
Client's Phone Number
Email*
example@example.com
1. intake assessment
Would you like an advocate present for this form?

yesno
Who is the best contact for appointments?

Cient:Other
Other please specify
Preferred method of contact

PhoneEmail
When is the best time to make contact/appointments?

AnytimeMorningAfternoon
Interpreter required?

yesno
Cultural considerations?

yesno
If yes please specify
Does the client have an authorised person, guardian, or nominee in place?

yesno
If yes please specify
Are there any current legal orders in place?

yesno
If yes please specify
Service Requests
Services client wishes to engage

Refer to Service agreement
How many hours per week to allocate?

Refer to Service agreement
Primary goals for service:

Refer to support plan
Is this the client's first NDIS plan?

NoYes
What are the dates of the plan?

Refer service agreement
What are the dates of the plan?

Refer service agreement
Consent to share a copy of the NDIS plan

Refer to Service agreement
Have you shared a copy of NDIS plan

yesnoCopy providedcopy NOT provided
Is there a current Behaviour Support Plan in place?

yesnoCopy provided?Copy NOT Provided
Is there anything additional you would like to share before engaging in services?
Safety assessment and consent
Are you aware of anything that would be a danger to a visiting worker at your residence?

YesNoNot Applicable will NOT be providing home visits SKIP TO END
If yes please specify
Do you live with anyone?

Yes:No
If yes, what is their relationship to you
Are they ever violent or aggressive towards anyone?

Yes:No
What type of housing do you live in?

PrivatePublicSupported accomodationAge careOther
Do you have anything in your house that would make it unsafe for workers to visit?

Yes:NoNot Applicable
Do you have animals?

Yes:NoNot Applicable
Are there any weapons on the property?

Yes:NoNot Applicable
Does anyone smoke on the premises?

Yes:NoNot Applicable
Is there any alcohol or drug use on the premises? Does anyone smoke on the premises?

Yes:NoNot Applicable
Is there anything additional you would like to share relevant to services?

Yes:No
if yes, please specify
Were there any risks Identified?

No - skip to endYes
If yes, what are they? Risk Management plan required (see below)
Risk Assessment and Management

Review the consequence table and select a consequence category. In the worst-case scenario, what would be the potential consequence of the identified risk(s)? Assign a consequence rating. Review the likelihood table and select the likelihood that the identified risk(s) will result in the potential consequence (according to the worst-case scenario Assign a likelihood rating. Plot the consequence rating and likelihood rating on the risk matrix. The combined rating will either be Low, Moderate, High or Extreme. This is the Risk rating.
Risk management plan

A risk management plan should be developed for any high and extreme risks identified (or lower, as preferred/required), and consists of additional controls that can be implemented to minimise the risk. Timelines and the individual responsible for implementing each control measure should form part of the plan. The plan should be monitored to ensure that agreed actions are completed, review dates should be specified, and the review should measure effectiveness of the control implemented.
Risk Factor(s)
Cause/Factors contributing to this risk
Impact: What is the impact of this risk?
Evidence of risk Include description and source(s) of information. Supporting evidence may be attached.
Controls What actions are planned/have been implemented in order to manage this risk? If implemented, state when and detail the outcome so far.
Monitoring How are you monitoring the risk?
Date of original risk assessment

MonthDayYear
Date
Risk Factor/Hazard
Consequence Rating
Likelihood Rating
Combined Rating

Risk rating

	insignificant No injuries or harm suffered	Minor First aid treatment applied	Minor Medication treatment- potential long term harm	major Permanent Disability/disease suffered	Severe Fatalities involved
Rare may occur in exceptional circumstances
Unlikly Could occur occasionally
Possible Expected to occur occasionally
Likely Expected to occur regularly
Almost Certain Expected to occur frequently

Date of subsequent risk assessment (to monitor effectiveness of controls) Likelihood Rating Consequence Rating

MonthDayYear
Date
Consequence Rating
Likelihood Rating
Combined Rating

Risk rating

	insignificant No injuries or harm suffered	Minor First aid treatment applied	Minor Medication treatment- potential long term harm	major Permanent Disability/disease suffered	Severe Fatalities involved
Rare may occur in exceptional circumstances
Unlikly Could occur occasionally
Possible Expected to occur occasionally
Likely Expected to occur regularly
Almost Certain Expected to occur frequently

Review: By the date specified in the agreed risk action plan, or earlier if circumstances change:

Gather information and update the risk assessment tool document

Record the revised risk rating on the Risk Assessment Tool
Date

MonthDayYear
Date
Signature

Clear
Should be Empty:

Cross Care

1. intake assessment

Service Requests

Safety assessment and consent

Risk Factor/Hazard