Risk Assessment Form
Name of person completing the Risks
First Name
Last Name
Organisation/Agency Name
Position
Name of Person Being Assessed
First Name
Last Name
Please select potential areas of risk taking into account past and present risk issues. Note any restrictions on locations etc. It is necessary for the referrer to provide risk information in order for the referral to be processed, to develop a risk management plan should the referral be accepted and to address support needs around risk management.
Rows
Yes
No
Low
Medium
High
Isolation or self neglect
Self harm
Suicidal thoughts or attempts
Excessive risk taking or self-destructive behaviour
Substance misuse
Exploitation/at risk from anoer person/s from others
Child/adult protection risks
Violence or aggression to others (peers, family etc)
Violence or aggression towards strangers
Violence or aggression towards staff
Sexual offending
Sexually inappropriate conduct
Any known gang affiliations?
Any restrictions? (Such as unable to visit certain areas within London due to offence/other behaviour)
Please give further details of the above i.e. known triggers, management of risk, protective and inflammatory factors and interventions to reduce risk
Please use the space below to provide more details about identified risks
Date of evaluation
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Signature
Submit
Submit
Should be Empty: