Clinician Assesment Form - Richmond Wellbeing

Brief Risk Assessment

Surname:*

Forenames:*

UMRN:*

Sex:

Patient's Address:

Bithdate:

MM

DD

YYYY

Source of Information:

Previous clinical records
Assessing clinician's knowledge of consumer's past behaviour/current clinical presentation
Medical Practitioner
Police/ambulance/other agencies
Others (please specify)

Please specify other source of information:

Suicidality

Static (Historical) Factors

Previous attempt(s) on own life:

Yes
No
Not known

Previous serious attempt:

Yes
No
Not known

Family history of suicide:

Yes
No
Not known

Major psychiatric diagnosis:

Yes
No
Not known

Major physical disability/illness:

Yes
No
Not known

Separated/widowed/divorced:

Yes
No
Not known

Loss of job/retired:

Yes
No
Not known

Dynamic (Current) Risk Factors

Expressing suicidal ideas:

Yes
No
Not Known

Has plan/intent:

Yes
No
Not Known

Express high level of distress:

Yes
No
Not Known

Hopelessness/perceived loss of coping or control over life:

Yes
No
Not Known

Recent significant life event:

Yes
No
Not Known

Reduced ability to control self:

Yes
No
Not Known

Current misuse of drugs/alcohol:

Yes
No
Not Known

Protective Factors (Describe)

Level of Suicide Risk

Total Score:*

LOW (<7)
MODERATE (7-14)
HIGH (>14)

Aggression/Violence

Static (Historical) Factors

Recent incidents of violence:

Yes
No
Not Known

Previous use of weapons:

Yes
No
Not Known

Male:

Yes
No
Not Known

Under 35 years old:

Yes
No
Not Known

Criminal history:

Yes
No
Not Known

Previous dangerous acts

Yes
No
Not Known

Childhood abuse:

Yes
No
Not Known

Role instability:

Yes
No
Not Known

History of drug/alcohol misuse:

Yes
No
Not Known

Dynamic (Current) Risk Factors

Expressing intent to harm others:

Yes
No
Not Known

Access to available means:

Yes
No
Not Known

Paranoid ideation about others:

Yes
No
Not Known

Violent comman hallucinations:

Yes
No
Not Known

Anger, frustration or agitation:

Yes
No
Not Known

Preoccupation with violent ideas:

Yes
No
Not Known

Inappropriate sexual behaviour:

Yes
No
Not Known

Reduced ability to control self:

Yes
No
Not Known

Current misuse of drugs/alcohol:

Yes
No
Not Known

Protective Factors (Describe)

Level of Suicide Risk

Total Score:*

LOW (<7)
MODERATE (7-14)
HIGH (>14)

Other Risks Identified (and Risk Factors)

Risk Management Issues

(Please ensure alerts are noted here)

Clinician Details

(To be completed by assessing clinician)

Full Name:

First Last

Signature:*

Date:

Organisation/Facility:

Position Held:

Address:

Phone:

Medical Practitioner Details

(Where appropriate, management plan to be acknowledged by requesting medical practitioner)

Full Name:

First Last

Designation:

Date:

Signature: