Self Referral Risk Assessment of risk (please rate the following): Referrer’s/person’s perception Risk/Level None Low Medium High Not known Of self injury To others - public To others - staff To property Of isolation Of self neglect Of relapse Of offending Is the person being referred subject to any MAPPA MARAC CAF CTO Probation of the following? (Tick as appropriate) Is there any risk issues (including criminal convictions) involved YES / NO / NOT KNOWN in visiting the client? If YES, please specify For agencies making the referral PLEASE ENCLOSE A FACE RISK ASSESSMENT (or other appropriate risk assessment) Self-referrals information sharing explained and agreed – (please tick box) Date completed Assessment, Outcome Star, FACE risk Support Plan CLIENT NOTES (for Positive Pathways use only)
Self Referral Risk Assessment Referrer’s/person’s perception of risk (please rate the following): Risk/Level None Low Medium High Not known Of self injury To others - public To others - staff To property Of isolation Of self neglect Of relapse Of offending Is the person being referred subject to any of the following? (Tick as appropriate) MAPPA MARAC CAF CTO Probation Is there any risk issues (including criminal convictions) involved in visiting the client? YES / NO / NOT KNOWN If YES, please specify For agencies making the referral PLEASE ENCLOSE A FACE RISK ASSESSMENT (or other appropriate risk assessment) Self-referrals – information sharing explained and agreed (please tick box) Date completed Assessment, Outcome Star, FACE risk Support Plan CLIENT NOTES (for Positive Pathways use only)
Positive_Pathways_referral_form1.docx