undergoing a timescales, agency detox involvement etc); programme? LEGAL SITUATION Has the Service User ever If YES please provide further details; been convicted of a serious YES NO violent offence? Has the Service User ever If YES please provide further details; YES NO been convicted of an Arson offence? Has the Service User ever If YES please provide further details; been convicted of a sexual YES NO offence? Any warrants outstanding? If YES please provide further details; YES NO Is the Service User on Bail, If YES bail conditions MUST be attached; Supervision Order or due to YES NO appear in court? Is the Service User registered If YES please provide further details (name of probation officer); with probation? YES NO Can you provide details of Prison Number any current or outstanding (if applicable) charges or sentences you are Release Date (if serving, be sure to include applicable) dates of outstanding cases or release etc. SECTION 4 RISK ASSESSMENT – When completing this please consider whether any risk applies to the service user, others and from others. LOW: Minimal MEDIUM: Significant but Stable HIGH: Significant & Volatile Risk of Harm to Others (Violence & Yes No LOW MEDIUM HIGH FURTHER COMMENT Abuse) (inc known triggers) 1.Current behaviour/demeanour is threatening or abusive 2. Previous incidents of violence or physical aggression 3. Expressing intent to harm others 4. Evidence of intent to harm others (e.g. keeps weapons) 5. Poor engagement with services and/or concern expressed by others 6. Poor engagement with care/support plan 7. History of drug/alcohol misuse Risk of Harm to Others (Violence & Yes No LOW HIGH FURTHER COMMENT MEDIUM Abuse) (inc known triggers) 8. Custodial sentences or arrest for violent behaviour 9. Previous history of abusing others 10.Close associates known to be aggressive
undergoing a detox programme? timescales, agency involvement etc); LEGAL SITUATION Has the Service User ever been convicted of a serious violent offence? YES NO If YES please provide further details; Has the Service User ever been convicted of an Arson offence? YES NO If YES please provide further details; Has the Service User ever been convicted of a sexual offence? YES NO If YES please provide further details; Any warrants outstanding? YES NO If YES please provide further details; Is the Service User on Bail, Supervision Order or due to appear in court? YES NO If YES bail conditions MUST be attached; Is the Service User registered with probation? YES NO If YES please provide further details (name of probation officer); Can you provide details of any current or outstanding charges or sentences you are serving, be sure to include dates of outstanding cases or release etc. Prison Number (if applicable) Release Date (if applicable) SECTION 4 – RISK ASSESSMENT When completing this please consider whether any risk applies to the service user, others and from others. LOW: Minimal MEDIUM: Significant but Stable HIGH: Significant & Volatile Risk of Harm to Others (Violence & Abuse) Yes No LOW MEDIUM HIGH FURTHER COMMENT (inc known triggers) 1.Current behaviour/demeanour is threatening or abusive 2. Previous incidents of violence or physical aggression 3. Expressing intent to harm others 4. Evidence of intent to harm others (e.g. keeps weapons) 5. Poor engagement with services and/or concern expressed by others 6. Poor engagement with care/support plan 7. History of drug/alcohol misuse Risk of Harm to Others (Violence & Abuse) Yes No LOW MEDIUM HIGH FURTHER COMMENT (inc known triggers) 8. Custodial sentences or arrest for violent behaviour 9. Previous history of abusing others 10.Close associates known to be aggressive
NWMMREFERRALFORM080316.docx