Step 1
Step 2
Step 3
Page 1 of 3
Client Risk Assessment Page 1
All fields marked with
*
are required.
*
Client's Name:
*
Date of risk assessment:
-Month-
-Day-
-Year-
*
Address of location where assessment was performed:
*
Are there multiple therapy locations?
Choose one..
Yes
No
*
Are there pets?
Choose one..
Yes
No
*
Please list the types and estimated sizes of pets:
*
Do the pets have a history of biting or jumping?
Choose one..
Yes
No
*
Is there a location for therapy?
Choose one..
Yes
No
*
Where is the therapy location?
*
Is the way to the therapy location free of clutter?
*
Is the therapy location in the basement?
Choose one..
Yes
No
*
Does the basement have a walk out exit?
Choose one..
Yes
No
*
Are there any fire alarms in the home?
Choose one..
Yes
No
*
Are the fire alarms locked up and secure?
Choose one..
Yes
No
*
What types? How many?
*
Are there any smoke detectors in the home?
Choose one..
Yes
No
*
Do the smoke detectors work?
Choose one..
Yes
No
*
Are there any carbon monoxide detectors?
Choose one..
Yes
No
*
Do the carbon monoxide detectors work?
Choose one..
Yes
No
*
Is there a fire extinguisher(s)?
Choose one..
Yes
No
*
Where is the location of the fire extinguisher(s)?
*
Is there a disaster location in the home?
Choose one..
Yes
No
*
Where is the disaster location?
*
If there are stairs in the home are they free of clutter?
Choose one..
Yes
No
*
Is the handrail on stairs secure?
Choose one..
Yes
No
*
Is this a smoke free home?
Choose one..
Yes
No
*
Is the home well kept and reasonably free of clutter?
Choose one..
Yes
No
*
Are the bathrooms reasonably clean?
Choose one..
Yes
No
*
Are the exits free and clear?
Choose one..
Yes
No
*
Location of Front exit(s)?
*
Location of Rear exit(s)?
*
Location of basement exit(s)?
*
Are the exits free and clear?
Choose one..
Yes
No
*
Doors are easily opened and closed?
Choose one..
Yes
No
*
Please enter any notes, comments or observations not listed above.
*
Check all that apply: "Is the home"
Single family
Town Home
Apartment
*
If an apartment what floor is the residence on?
*
Is there an elevator or stairs?
Choose one..
Elevator
Stairs
*
Check all that apply: "Others present in the home"
Siblings
Grand Parents
Extended family members
Roommates
Other
*
Is access in to the house locked at all times?
Choose one..
Yes
No
*
Is there a pool?
Choose one..
Yes
No
*
Is the entry to the pool gated and locked?
Choose one..
Yes
No
*
Is the food preparation area clean?
Choose one..
Yes
No
*
Is there a play set in the backyard?
Choose one..
Yes
No
*
Are all parts stable and in working order?
Choose one..
Yes
No
*
Is the backyard fenced in?
Choose one..
Yes
No
Page 2 of 3
Client Risk Assessment Page 2
All fields marked with
*
are required.
Please answer Yes or No to the following:
Comments
*
Is the client a victim of physical abuse?
Yes
No
*
Is the client a victim of sexual abuse?
Yes
No
*
Is the client a victim of neglect or significant maltreatment?
Yes
No
*
Has the client been exposed to domestic violence?
Yes
No
*
Has the client been exposed to excessive violence in the community?
Yes
No
*
Has the client had more than two different primary caretakers in his/her lifetime?
Yes
No
*
Does the client have a history of being oppositional and defiant at home (a history of not following rules set by parents)?
Yes
No
*
Is there any pattern of physical or verbal aggression by the client at home?
Yes
No
*
Is there any family history of criminal behavior?
Yes
No
*
Has the client ever failed a grade?
Yes
No
*
Is the client LD or ED?
Yes
No
*
Has the client ever been suspended out of school more than twice?
Yes
No
*
Has the client ever been expelled from school?
Yes
No
*
Does the client refrain from involvement in school activities or clubs?
Yes
No
*
Does the client have a history of behavior problems at school?
Yes
No
*
Has the client ever held a job?
Yes
No
*
If so, has he/she ever been fired from a job?
Yes
No
*
Has the client ever been hospitalized for psychiatric reasons?
Yes
No
*
Are there any reports or does the client exhibit signs of paranoid thinking?
Yes
No
*
Does the client have a history of fighting (more than 5 fights)?
Yes
No
*
Has the client ever caused someone to be seriously injured from a fight?
Yes
No
*
Has the client ever carried a weapon?
Yes
No
*
Has the client ever been involved with a gang?
Yes
No
*
If the client is male, has he ever hit a female because she made him mad?
Yes
No
*
Is there any information available that indicates that the client is a bully?
Yes
No
*
Is the client manipulative?
Yes
No
*
Is the client pathologically narcissistic?
Yes
No
*
Does the client have a pattern or never taking responsibility for his/her misbehaviors?
Yes
No
*
Does the client lie frequently?
Yes
No
*
Is there any history of animal abuse or torture by the client?
Yes
No
*
Is there any history of fire-setting by the client?
Yes
No
*
Is the peer group that the client spends the most time with criminal or considered a negative influence?
Yes
No
*
Is the client a social misfit or under socialized?
Yes
No
*
Does the client have anger management problems?
Yes
No
*
Is the client extremely impulsive?
Yes
No
*
Has the client been diagnosed with ADHD?
Yes
No
*
Does the client lack remorse?
Yes
No
*
Any suspected current substance abuse issues with the client?
Yes
No
*
Any suspected current substance abuse issues with the family?
Yes
No
*
Does the client have a history of property crimes?
Yes
No
*
Does the client have a history of violent/assaultive crimes?
Yes
No
*
Has the client ever been charged with a sexual offense?
Yes
No
*
Has the client ever failed on community supervision or been violated?
Yes
No
*
Does the client have sexual identity issues?
Yes
No
*
Does the client have a history of excessive use of pornography/erotica?
Yes
No
*
Was the client exposed to erotica at an early age (before 10)?
Yes
No
*
Is there any evidence of compulsive sexual behaviors by the client (i.e., excessive masturbation)?
Yes
No
*
Have there been complaints of boundary violations and over-familiar touching by the client?
Yes
No
*
Does the client have diagnosed mental health issues?
Yes
No
*
Does the client have any signs of a thought disorder?
Yes
No
*
Does the client take any medication?
Yes
No
*
Does the Client have a stable home environment in terms of placement?
Yes
No
*
Are the caretaker(s) supportive of intervention services?
Yes
No
*
Are the caretaker(s) capable and willing to hold the client accountable?
Yes
No
*
Does the client have potential victims in the home?
Yes
No
*
If the client has significant mental health issues, is he/she stable now?
Yes
No
*
Is the client on probation?
Yes
No
*
Does the client appear to be amenable to treatment?
Yes
No
*
Is the client motivated to participate in treatment?
Yes
No
*
Are there services available to address the client's issues?
Yes
No
*
Does the client have access to a positive support system?
Yes
No
*
Does the client do well in school or is he/she involved in school activities?
Yes
No
*
Has the client benefited from mental health services in the past?
Yes
No
*
Does the client have a history of compliance with authority?
Yes
No
Page 3 of 3
Client Risk Assessment Page 3
All fields marked with
*
are required.
*
Has the client ever been non-compliant with prescribed medications?
Choose one..
Yes
No
*
Please enter any notes, comments or observations not listed above.
*
Has the client ever attempted suicide?
Choose one..
Yes
No
*
What were the suicidal or homicidal behaviors? Include dates, method and lethality.
*
Does the client express any current suicidal or homicidal ideation?
*
Does the client/family have a history of substance abuse?
Choose one..
Yes
No
*
Substance Abuse. If the client has an active alcohol or substance abuse problem, has intervention occurred? If so, provide documentation.
*
Substance Abuse. Provide documentation of past and present use of alcohol, nicotine, illicit drugs, prescription drugs and over the counter drugs.
*
Does the client have a history of criminal/court involvement?
Choose one..
Yes
No
*
Legal Issues. Are there any present relevant legal issues of the client and/or family? If yes, please provide a summary.
*
Is the client currently sexually active?
Choose one..
Yes
No
*
Is the client promiscuous in his/her sexual behavior?
Choose one..
Yes
No
*
Provide sexual behavior history
*
Does the client have any history of sexual offending behavior(s)?
Choose one..
Yes
No
*
Provide details of the sexual offending behavior(s).