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Date*
Client Name*
Date of Birth
Address
Does this person have a guardian?
Is this individual under a commitment?

Risk Assessment

History of suicide attempts?
Recent loss of a loved one?
Currently expressing suicidal ideation?
Thoughts/history of self-harm (cutting, burning, etc.)?
Any recent aggressive/assaultive behaviors?
Is client experiencing auditory or visual hallucinations?
Is the client having delusional thoughts?
Are there concerns about housing, childcare, employment, and/or health?
Has client had recent chemical use?
Family Supports
Current Symptoms*
i.e. prompt/support client in getting prescriptions filled, ensure client is following up with community supports, assist client in setting up structure to their day, etc.
What is the anticipated discharge date?
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