Page 1 of 3

Client Risk Assessment Page 1

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*Client's Name:

*D.O.B:

*Address of location where assessment was performed:

CLIENT HOME SAFETY

*Are there pets?

*Please list the types and estimated sizes of pets:

*Do the pets have a history of biting or jumping?

*Is there a location for therapy?

*Where is the therapy location?

*Is the way to the therapy location free of clutter?

*Is the therapy location in the basement?

*Does the basement have a walk out exit?

*Are there any firearms in the home?

*Are they in a gun safe or securely locked up?

*Are there any smoke detectors in the home?

*Do the smoke detectors work?

*Are there any carbon monoxide detectors?

*Do the carbon monoxide detectors work?

*Is there a fire extinguisher(s)?

*Where is the location of the fire extinguisher(s)?

*Is there a disaster location in the home?

*Where is the disaster location?

*If there are stairs in the home are they free of clutter?

*Is the handrail on stairs secure?

*Is this a smoke free home?

*Is the home well kept and reasonably free of clutter?

*Are the bathrooms reasonably clean?

*Are the exits free and clear?

*Location of Front exit(s)?

*Location of Rear exit(s)?

*Location of basement exit(s)?

*Are the exits free and clear?

*Doors are easily opened and closed?

Page 3 of 3

Client Risk Assessment Page 3

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*What were the suicidal or homicidal behaviors? Include dates, method and lethality.

*Provide sexual behavior history

*Substance Abuse. Provide documentation of past and present use of alcohol, nicotine, illicit drugs, prescription drugs and over the counter drugs.

*Substance Abuse. If the client has an active alcohol or substance abuse problem, has intervention occurred? If so, provide documentation.

*Legal Issues. Are there any present relevant legal issues of the client and/or family? If yes, please provide a summary.

PARENT/GUARDIAN NAME:

DATE:

PARENT/GUARDIAN SIGNATURE:

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Client Risk Assessment Page 1

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Client Risk Assessment Page 2

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Please answer Yes or No to the following:

Client Risk Assessment Page 3

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