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

Date

Client's NDIS Number

Client's Address

Client's Phone Number

Format: (000) 000-0000.

Email

example@example.com

Would you like an advocate present for this form?

Who is the best contact for appointments?

Other please specify

Preferred method of contact

When is the best time to make contact/appointments?

Interpreter required?

Cultural considerations?

If yes please specify

Does the client have an authorised person, guardian, or nominee in place?

If yes please specify

Are there any current legal orders in place?

If yes please specify

Services client wishes to engage

How many hours per week to allocate?

Primary goals for service:

Is this the client's first NDIS plan?

What are the dates of the plan?

Consent to share a copy of the NDIS plan

Have you shared a copy of NDIS plan

Is there a current Behaviour Support Plan in place?

Is there anything additional you would like to share before engaging in services?

Are you aware of anything that would be a danger to a visiting worker at your residence?

If yes please specify

Do you live with anyone?

If yes, what is their relationship to you

Are they ever violent or aggressive towards anyone?

What type of housing do you live in?

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

Do you have animals?

Are there any weapons on the property?

Does anyone smoke on the premises?

Is there any alcohol or drug use on the premises? Does anyone smoke on the premises?

Is there anything additional you would like to share relevant to services?

if yes, please specify

Were there any risks Identified?

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

Date

Consequence Rating

Likelihood Rating

Combined Rating

Risk rating

Rows	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

Date

Consequence Rating

Likelihood Rating

Combined Rating

Risk rating

Rows	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

Signature

Cross Care

1. intake assessment

Service Requests

Safety assessment and consent

Risk Factor/Hazard