3 LEVEL OF SUPPORT 2 RISK OF HARM TO OTHERS 1 RISK OF HARM TO SELF AVAILABLE No problems/ Highly Supportive (all aspects/ most aspects highly None (No thoughts or action of None (No thoughts or actions of supportive/ self/ family/ ☐ ☐ ☐ harm harm) professional/ effective involvement) Low (Fleeting suicidal thoughts Low (Fleeting "harm to others" Moderately Supportive (variety but no plans/current low alcohol thoughts but no plans/ current of support available, able to help ☐ ☐ ☐ or drug use) low alcohol or drug use) in of need) Moderate (current thoughts/ Moderate (current thoughts/ Limited Support (few sources of distress/ past actions without distress/ past actions without help, support system has ☐ ☐ ☐ intent or plans/ moderate alcohol intent or plans/ moderate alcohol incomplete ability to participate or drug use) or drug use) in treatment) Significant (current thoughts/ Significant (current thoughts / past impulsive actions/ recent past impulsive actions/ recent Minimal (few sources of support impulsivity/ some plans, but not impulsivity/ some plans, but not ☐ ☐ ☐ and not motivated) well developed/ increased well developed/ increased alcohol or drug use) alcohol or drug use) Extreme (current thoughts with Extreme (current thoughts with expressed intensions/ past expressed intensions/ past history/ plans/ unstable mental history/ plans/ unstable mental No support in all areas ☐ ☐ ☐ illness/ high alcohol or drug use, illness/ high alcohol or drug use, intoxicated/ violent to self/ intoxicated/ violent to self/ means at harm to harm self) means at harm to harm self) Reason(s) for Referral to Partners in Recovery: The referrer has explained the purpose of this referral and I give permission for them to discuss and communicate with the Partners in Recovery (PIR) Facilitator so they may contribute towards my care. Client Signature: Referrers Signature: Date: / / 2015
1 RISK OF HARM TO SELF 2 RISK OF HARM TO OTHERS 3 LEVEL OF SUPPORT AVAILABLE ☐ None (No thoughts or action of harm ☐ None (No thoughts or actions of harm) ☐ No problems/ Highly Supportive (all aspects/ most aspects highly supportive/ self/ family/ professional/ effective involvement) ☐ Low (Fleeting suicidal thoughts but no plans/current low alcohol or drug use) ☐ Low (Fleeting "harm to others" thoughts but no plans/ current low alcohol or drug use) ☐ Moderately Supportive (variety of support available, able to help in of need) ☐ Moderate (current thoughts/ distress/ past actions without intent or plans/ moderate alcohol or drug use) ☐ Moderate (current thoughts/ distress/ past actions without intent or plans/ moderate alcohol or drug use) ☐ Limited Support (few sources of help, support system has incomplete ability to participate in treatment) ☐ Significant (current thoughts/ past impulsive actions/ recent impulsivity/ some plans, but not well developed/ increased alcohol or drug use) ☐ Significant (current thoughts / past impulsive actions/ recent impulsivity/ some plans, but not well developed/ increased alcohol or drug use) ☐ Minimal (few sources of support and not motivated) ☐ Extreme (current thoughts with expressed intensions/ past history/ plans/ unstable mental illness/ high alcohol or drug use, intoxicated/ violent to self/ means at harm to harm self) ☐ Extreme (current thoughts with expressed intensions/ past history/ plans/ unstable mental illness/ high alcohol or drug use, intoxicated/ violent to self/ means at harm to harm self) ☐ No support in all areas Reason(s) for Referral to Partners in Recovery: The referrer has explained the purpose of this referral and I give permission for them to discuss and communicate with the Partners in Recovery (PIR) Facilitator so they may contribute towards my care. Client Signature: Referrers Signature: Date: / / 2015