RISK ASSESSMENT For referring AgenciesFORM (R1)

PRIVATE AND CONFIDENTIAL

Name of Applicant / Date of Birth
Framework HA will treat all risk assessment information with sensitivity. Sometimes we need to ask for more detail about an issue. Are there any responses to questions on this form that the applicant does not wish to talk to us about directly? If yes, please attach a qualifying note. Who may we approach?
Dangerous behaviour / Yes / No / Emotional/mental health issues / Yes / No
Known incidents of violence / Yes / No / Detained under the Mental Health Act / Yes / No
If yes, to whom? / Known suicide attempts / Yes / No
Staff / Yes / No / Known self-harm / Yes / No
Public / Yes / No / Dual diagnosis / Yes / No
Friends / Yes / No / Concerning behaviours / Yes / No
Family / Yes / No / Self-care/risk from others / Yes / No
Most serious damage caused: / History of serious self-neglect / Yes / No
None / Yes / No / History of being abused /exploited / Yes / No
Serious Injury / Yes / No / History of being harassed / Yes / No
Minor Injury / Yes / No / Accidental harm (kitchen fires) / Yes / No
Death / Yes / No / Persistent provocative behaviour
Damage to property / Yes / No
Known incidents of abuse or harassment to others / Yes / No / Known risk to children / Yes / No
Verbal aggression to others / Yes / No / Problems managing anger/impulsive behaviour / Yes / No
Sexual assault/exposure / Yes / No / Arson / Yes / No
Substance Misuse / Yes / No / Alcohol Misuse / Yes / No
Referrer’s name
Referrer’s Signature
Referrer’s organisation
Date completed

Risk Indicators Checklist

Please use these prompts to assist you in completing the risk assessment form, the lists are not exhaustive.

General Indicators:

  • Drug/alcohol misuse
  • Medication misuse
  • Significant criminal offences
  • Psychiatric admissions under the Mental Health Act or Supervised Discharge
  • Client is the subject of the Care Programme Approach or s117 of the Mental Health Act Psychiatric diagnosis
  • Recent loss
  • Disorientation / hallucinations / delusions
  • History of violence, arson, sexual offence
  • Inappropriate sexual behaviour
  • History of violence to animals
  • History of suffering violence from others
  • Tolerance threshold low
  • Difficult / resistant / antagonistic or disordered / abusive behaviour
  • Threats – specific / general
  • Plans / accumulation of materials or weapons
  • Lack of personal safety (e.g. fire risk, road sense, food hygiene etc)
  • Physical illness
  • Depression
  • Self neglect
  • Suicide attempts / thoughts
  • Persistent annoying behaviour
  • Incidents of harassment

Who is at risk?

  • Service User them self
  • Other Service Users
  • Neighbour
  • Partner
  • Child/Children
  • Lodger
  • Framework Staff
  • Relative
  • Friend
  • Member of the public
  • Another agency worker

Is the risk general or to specific individuals or groups?