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Mental Health Risk Assessment Form

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Mental Health Risk Assessment Form

Audit

SELF-HARM/SUICIDE

Does the patient have a history of hurting themselves?

Does the patient's family have a history of suicide or self-harm?

Is the patient in a low mood?

Has the patient hinted on suicidal ideation?

Has the patient experienced any recent adverse life events?

Is the patient in a high level of distress?

Is the patient suffering from a physical illness or disability?

Does the patient live alone? (Or will live alone after discharge?)

Has the patient been feeling isolated from society?

Was the patient recently discharged from a hospital/prison?

Did the patient's significant other express any concerns about them?

Does the patient have a criminal record?

List all of the offences here.

Any other observations related to self-harm.

CURRENT STATUS

Is the patient demonstrating any hostile or threatening behavior?

Has the patient expressed any violent thoughts or fantasies?

Does the patient have problems controlling their temper?

Does the patient possess weapons with possible intent to use?

Is there a current risk of violence from the patient?

Does the patient have access to a potential or threatened victim?

Has the patient expressed ongoing drug or alcohol misuse?

Have others expressed concern about potential violence from the patient?

Any other observations related to the patient's current status.

HISTORY

Does the patient have a history of violence?

Does the patient have a history of disengagement from services? (the patient has previously "dropped out" of a mental health care program)

Has the patient witnessed violence and/or emotional abuse in childhood?

Has the patient experienced violence and/or emotional abuse in childhood?

Does the patient have a history of deliberate or accidental fire setting?

Does the patient have a history of deliberately harming other people?

Does the patient have a history of deliberately harming children?

Any other observations related to the patient's history.

SERIOUS SELF-NEGLECT

Is the patient currently homeless?

Is the patient currently subject to unacceptable living conditions (e.g. hazards)?

Is the patient socially isolated? (e.g. refuses to talk to friends and family or has none)

Is the patient dehydrated?

Is the patient malnourished?

Does the patient have poor hygiene? (e.g. has verbally expressed poor hygienic practices or evident in appearance and scent)

Does the patient risk causing accidents for themselves or others due to negligence/apathy? (e.g. does not follow traffic lights, crosses the street with no regard for ongoing traffic)

Does the patient have any untreated physical health needs?

Does the patient have a history of persistent non-compliance with prescribed medication?

Does the patient have a history of alcohol abuse?

Does the patient have a history of substance abuse?

Any other observations.

EXPLOITATION/VULNERABILITY

Is the patient currently, or was previously at risk of physical abuse?

Is the patient currently, or was previously at risk of sexual abuse?

Is the patient currently, or was previously at risk of social abuse?

Is the patient currently, or was previously at risk of emotional abuse?

Is the patient currently, or was previously at risk of financial abuse?

Are there threats against the patients privacy and dignity (past and/or present)?

Is the patient displaying symptoms of disinhibition?

Is the patient displaying symptoms of impulsiveness?

Is the patient displaying precocious behavior?

Is the patient living in unacceptable home conditions (e.g. hazards)?

Any other observations.

SUMMARY RISK ASSESSMENT

Overall likelihood to cause self-harm/ harm to others

Severity of self-harm/ harm to others

Overall risk rating

Summary findings on degree of risk and recommendations

Health professional signature

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Please note that this checklist template is a hypothetical appuses-hero example and provides only standard information. The template does not aim to replace, among other things, workplace, health and safety advice, medical advice, diagnosis or treatment, or any other applicable law. You should seek your professional advice to determine whether the use of such a checklist is appropriate in your workplace or jurisdiction.

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