| 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. |
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| 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 | ||
| Notes:
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| Assessor’s Name : |
Assessor’s Signature: | ||
| Date & Time : | |||