Risk Assessment (from Western ACIS)

Safety and the use of this assessment

Please tick all relevant boxes. It is important to note that this checklist has been developed as a set of questions, which will assist your clinical risk assessment. It is NOT intended to be used as a score sheet in which you add the number of ticks to determine the level of risk. A tick in just one box [eg the client is armed with a firearm] may make them an extreme risk. Furthermore the assessment of risk must account for other global aspects of the clients history as well as your mental state assessment.

Factors relevant to both Suicide/self harm risk & dangerousness
1 History of psychiatric illness  
2 Psychiatric illness which is currently active  
3 Overtly psychotic  
4 History of organic brain disorder [eg closed head injury, epilepsy]  
5 History of alcohol abuse  
6 History of abuse of illicit or prescribed drugs  
7 Currently intoxicated  
8 Recent history of separation, divorce, relationship breakdown or major loss  
Factors relevant specifically to Suicide/self harm risk
9 Has experienced suicidal thoughts  
10 States intention to kill self  
11 Has made plans to kill self  
12 Finalized affairs in anticipation of death  
13 No future life plans  
14 Previous suicide attempts  
15 Previous suicide attempts by high lethality or violent methods  
16 No immediate social supports  
17 Chronic painful or debilitating physical condition  
18 Family history of suicide attempts  
Factors relevant specifically to dangerousness risk
19 States intent or has made plans to harm others  
20 You suspect client is currently armed [specify]  
21 Client has access to weapons [specify]  
22 Observed to be hostile, agitated, restless or pacing  
23 History of violence  
24 Forensic history  
25 Has been the victim of violence  


Assessor’s Name :
Assessor’s Signature:
Date & Time :