Q5. To what extent is the applicant at risk of the following? Please provide history (including dates) and current status. Please continue onto separate page if necessary. Self Harm: (e.g. any history, any available current None Low Medium High evidence, any conversations with others, date of last episode) Please give details: Suicide: (e.g. individual and family history, expressed None Low Medium High intentions, any current or historical triggers, any plans or methods in mind, date of last episode) Please give details: Risk to Others: (e.g. Physical or sexual abuse of None Low Medium High others, violent attitudes or aggressive behaviour, access to weapons, current and historical triggers) Please give details: Self Neglect: (e.g. lack of motivation, not eating and None Low Medium High drinking, personal hygiene, living skills) Please give details: Risk from Others: (e.g. domestic violence, child / None Low Medium High sexual, physical, emotional abuse, bullying, racial harassment) Please give details: Wellbeing: (e.g. depression, mental health, current None Low Medium High and historical factors, medication, trigger factors, diagnosis, counselling, date of last episode) Please give details: Arson: (e.g. expressed intentions, history, trigger None Low Medium High factors) Please give details: Addictions: (e.g. Substance misuse, gambling, sex, None Low Medium High history, trigger factors, counselling, date of last episode) Please give details: Section 6 Offending Behaviour Q6. Please give ALL details of anyone in households offending history, current status and risk assessment details from the Probation office where appropriate. Please note failure to disclose all information could result in the delay of the application being processed. Non disclosure of crimes could also result in withdrawal of services.
Q5. To what extent is the applicant at risk of the following? Please provide history (including dates) and current status. Please continue onto separate page if necessary. Self Harm: (e.g. any history, any available current evidence, any conversations with others, date of last episode) None Low Medium High Please give details: Suicide: (e.g. individual and family history, expressed intentions, any current or historical triggers, any plans or methods in mind, date of last episode) None Low Medium High Please give details: Risk to Others: (e.g. Physical or sexual abuse of others, violent attitudes or aggressive behaviour, access to weapons, current and historical triggers) None Low Medium High Please give details: Self Neglect: (e.g. lack of motivation, not eating and drinking, personal hygiene, living skills) None Low Medium High Please give details: Risk from Others: (e.g. domestic violence, child / sexual, physical, emotional abuse, bullying, racial harassment) None Low Medium High Please give details: Wellbeing: (e.g. depression, mental health, current and historical factors, medication, trigger factors, diagnosis, counselling, date of last episode) None Low Medium High Please give details: Arson: (e.g. expressed intentions, history, trigger factors) None Low Medium High Please give details: Addictions: (e.g. Substance misuse, gambling, sex, history, trigger factors, counselling, date of last episode) None Low Medium High Please give details: Section 6 Offending Behaviour Q6. Please give ALL details of anyone in households offending history, current status and risk assessment details from the Probation office where appropriate. Please note failure to disclose all information could result in the delay of the application being processed. Non disclosure of crimes could also result in withdrawal of services.