New Customer Registration Form

Comprehensive Client Risk Assessment Form - normally to be completed after the prospective client has had three initial visits to the day centre - estimated time to complete is 20 - 40 mins - there are about 40 questions about various risks but many may not apply so leave any box blank if the named risk above the box is not applicable (* means information is obligatory) Medical and other key information will be gathered via a separate form, namely Centa Co's Application / Referral Form which is normally completed before this risk assessment form is completed (available upon request - link also given at the end of this form)

Please provide examples if this will help plus any controls you currently employ to mitigate the risk. Please note that more detailed information can be gleaned later when Centa Co staff speak to you about any risks selected, delving in more depth about the risk described.
Any queries?

Email us:

contact@centa-co.com

or phone us:

07799 890635
Your full name:*

First NameLast Name
Client name in two initials:*

First Initial Second Initial
Your Tel. No. or your Organisation's Tel. No.: ☎️ (Please make sure you provide a contact telephone no. or email address or both):

Area CodePhone Number
Please don't forget to provide any examples of behaviours and also provide details of controls / strategies that work 🙂
Your Email Address or your Organisation's Email Address: 📨 (Please make sure you provide a contact telephone no. or email address or both):
example@example.com
1. Unable to maintain own safety e.g. due to level of learning disability / autism? - Please describe the nature of the risk plus give any examples or history
Controls / actions / strategies / info. that may help to reduce risk e.g. observe, supervise, reinforcement, hold arm or hand (leave blank if none known)
Priority rating assigned (to be completed by manager) - tick as necessary: High Medium Low
2. Requires regular observation and reinforcement to maintain safety? Please describe the nature of the risk plus give any examples or history
Controls / actions / strategies / info. that may help to reduce risk e.g. observe, supervise, reinforcement, hold arm or hand (leave blank if none known)
Priority rating assigned (to be completed by manager) - tick as necessary: High Medium Low
3. Requires hand or arm holding upon encountering hazards? e.g. when crossing roads or in crowds - Please describe the nature of the risk plus give any examples or history
Controls / actions / strategies / info. that may help to reduce risk e.g. observe, supervise, reinforcement, hold arm or hand (leave blank if none known)
Priority rating assigned (to be completed by manager) - tick as necessary: High Medium Low
4. Mobility issues / trips or falls / coordination - Please describe the nature of the risk plus give any examples or history
Controls / actions / strategies / info. that may help to reduce risk e.g. observe, supervise, reinforcement, hold arm or hand (leave blank if none known)
Priority rating assigned (to be completed by manager) - tick as necessary: High Medium Low
5. Approaching strangers / over trusting of strangers - Please describe the nature of the risk plus give any examples or history
Controls / actions / strategies / info. that may help to reduce risk e.g. observe, supervise, reinforcement, hold arm or hand (leave blank if none known)
Priority rating assigned (to be completed by manager) - tick as necessary: High Medium Low
6. Copying behaviour of others - Please describe the nature of the risk plus give any examples or history
Controls / actions / strategies / info. that may help to reduce risk e.g. observe, supervise, reinforcement, hold arm or hand (leave blank if none known)
Priority rating assigned (to be completed by manager) - tick as necessary: High Medium Low
7. Risk of wandering off / getting lost / disorientated (all places / just unfamiliar places?) - Please describe the nature of the risk plus give any examples or history
Controls / actions / strategies / info. that may help to reduce risk e.g. observe, supervise, reinforcement, hold arm or hand (leave blank if none known)
Priority rating assigned (to be completed by manager) - tick as necessary: High Medium Low
8. Vulnerability to abuse e.g. financial - Please describe the nature of the risk plus give any examples or history
Controls / actions / strategies / info. that may help to reduce risk e.g. observe, supervise, reinforcement, hold arm or hand (leave blank if none known)
Priority rating assigned (to be completed by manager) - tick as necessary: High Medium Low
9. Anxiety or meltdown in crowds e.g. in shopping centres - Please describe the nature of the risk plus give any examples or history
Controls / actions / strategies / info. that may help to reduce risk e.g. observe, supervise, reinforcement, hold arm or hand (leave blank if none known)
Priority rating assigned (to be completed by manager) - tick as necessary: High Medium Low
10. Fears or phobias e.g. dogs or wasps - Please describe the nature of the risk plus give any examples or history
Controls / actions / strategies / info. that may help to reduce risk e.g. observe, supervise, reinforcement, hold arm or hand (leave blank if none known)
Priority rating assigned (to be completed by manager) - tick as necessary: High Medium Low
11. Anxiety / meltdown triggers - Please describe the nature of the risk plus give any examples or history
Controls / actions / strategies / info. that may help to reduce risk e.g. observe, supervise, reinforcement, hold arm or hand (leave blank if none known)
Priority rating assigned (to be completed by manager) - tick as necessary: High Medium Low
12. Become anxious in new environments, needs reassurance and extra time to reduce anxiety - Please describe the nature of the risk plus give any examples or history
Controls / actions / strategies / info. that may help to reduce risk e.g. observe, supervise, reinforcement, hold arm or hand (leave blank if none known)
Priority rating assigned (to be completed by manager) - tick as necessary: High Medium Low
13. Social anxiety - Please describe the nature of the risk plus give any examples or history
Controls / actions / strategies / info. that may help to reduce risk e.g. observe, supervise, reinforcement, hold arm or hand (leave blank if none known)
Priority rating assigned (to be completed by manager) - tick as necessary: High Medium Low
14. Stress triggers - Please describe the nature of the risk plus give any examples or history
Controls / actions / strategies / info. that may help to reduce risk e.g. observe, supervise, reinforcement, hold arm or hand (leave blank if none known)
Priority rating assigned (to be completed by manager) - tick as necessary: High Medium Low
15. Lack of confidence - Please describe plus give any examples or history
Controls / actions / strategies / info. that may help to reduce risk e.g. observe, supervise, reinforcement, hold arm or hand (leave blank if none known)
Priority rating assigned (to be completed by manager) - tick as necessary: High Medium Low
16. Self harming behaviour - Please descirbe the nature of the risk plus give any examples or history
Controls / actions / strategies / info. that may help to reduce risk e.g. observe, supervise, reinforcement, hold arm or hand (leave blank if none known)
Priority rating assigned (to be completed by manager) - tick as necessary: High Medium Low
17. Sensory sensitivity e.g. bright or flashing lights, loud noises, smells etc - Please describe the nature of the risk plus give any examples or history
Controls / actions / strategies / info. that may help to reduce risk e.g. observe, supervise, reinforcement, hold arm or hand (leave blank if none known)
Priority rating assigned (to be completed by manager) - tick as necessary: High Medium Low
18. Repetitive behaviours / obsessions - Please describe plus give any examples or history
Controls / actions / strategies / info. that may help to reduce risk e.g. observe, supervise, reinforcement, hold arm or hand (leave blank if none known)
Priority rating assigned (to be completed by manager) - tick as necessary: High Medium Low
19. Paranoia e.g. thinks people are staring at them - Please describe plus give any examples or history
Controls / actions / strategies / info. that may help to reduce risk e.g. observe, supervise, reinforcement, hold arm or hand (leave blank if none known)
Priority rating assigned (to be completed by manager) - tick as necessary: High Medium Low
20. Mood fluctuations - Please describe plus give any examples or history
Controls / actions / strategies / info. that may help
Priority rating assigned (to be completed by manager) - tick as necessary: High Medium Low
21. Language challenges - Please describe plus give any examples or history
Controls / actions / strategies / info. that may help
Priority rating assigned (to be completed by manager) - tick as necessary: High Medium Low
22. Non-verbal? - Please describe plus give any examples
Controls / actions / strategies / info. that may help
Priority rating assigned (to be completed by manager) - tick as necessary: High Medium Low
23. Uses some non verbal signs, facial expressions, body language or behaviour to supplement verbal communication? - Please describe plus give any examples
Controls / actions / strategies / info. that may help
Priority rating assigned (to be completed by manager) - tick as necessary: High Medium Low
24. Requires additional time to process information and respond - Please describe plus give any examples
Controls / actions / strategies / info. that may help
Priority rating assigned (to be completed by manager) - tick as necessary: High Medium Low
25. Communication such that requires support from support workers to interpret need
Controls / actions / strategies / info. that may help
Priority rating assigned (to be completed by manager) - tick as necessary: High Medium Low
26. Sensory disability e.g. sight and / or hearing impaired - Please describe plus give any examples
Controls / actions / strategies / info. that may help
Priority rating assigned (to be completed by manager) - tick as necessary: High Medium Low
27. Mental Capacity Assessment information / past DoLS / requires reinforcement, extra time, accessible information to support decision making?
28. Challenging behaviours / destructive behaviours / inappropriate behaviours e.g. becomes upset and uncooperative if does not get way, gets aggressive when stuck in traffic, throws things, hits staff, strips clothes - needs clear boundaries and reinforcement - Please describe plus give any examples
Controls / actions / strategies / info. that may help to reduce risk e.g. observe, supervise, reinforcement, hold arm or hand (leave blank if none known)
Priority rating assigned (to be completed by manager) - tick as necessary: High Medium Low
29. Hyperactivity / over excitability - Please describe plus give any examples
Controls / actions / strategies / info. that may help to reduce risk e.g. observe, supervise, reinforcement, hold arm or hand (leave blank if none known)
Priority rating assigned (to be completed by manager) - tick as necessary: High Medium Low
30. Needs prompting on if they require the toilet / able to take self to toilet / requires personal care (any client requiring personal care will need to be accompanied by their own support worker) - Please describe plus give any examples
Controls / actions / strategies / info. that may help
Priority rating assigned (to be completed by manager) - tick as necessary: High Medium Low
31. Likely to increase risk to others e.g. leaving things on the floor / sudden movements / running around / knocking into others - Please describe plus give any examples
Controls / actions / strategies / info. that may help
Priority rating assigned (to be completed by manager) - tick as necessary: High Medium Low
32. Epilepsy - type / warning signs / triggers / are seizures well controlled by medication or infrequent? - if not give details Seizure activity is prolonged or difficult to recognise leading to loss of consciousness? Risk of airway obstruction or aspiration during seizures (history) / Buccal used? - Please describe plus give any examples
Controls / actions / strategies / info. that may help reduce the risk of a seizure
Priority rating assigned (to be completed by manager) - tick as necessary: High Medium Low
33. Risk choking on food or drink (dysphagia) / swallowing difficulties - Please describe plus give any examples
Controls / actions / strategies / info. that may help reduce the risk of choking
Priority rating assigned (to be completed by manager) - tick as necessary: High Medium Low
33. Able to make hot drinks unsupervised? - Please describe
34. Drinks alcohol? drug interaction risk? / limits? / behavioural changes? Please describe plus give any examples
35. Situations / places to avoid - Please describe why plus give any examples
Any other information you'd like to add
Any other information you'd like to add
Please make sure to provide contact details at the beginning of this form

Any queries ? Email us: contact@centa-co.com or phone 07799 890635
Link to Centa Co's Application/ Referral Form
Should be Empty:

Please don't forget to provide any examples of behaviours and also provide details of controls / strategies that work 🙂