Client Home Risk Assessment

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Client Home Risk Assessment

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Client Name*
Date of risk assessment*
Address the risk assessment was performed?*
Are there multiple therapy locations?*
- Yes
- No
Are there pets?*
- Yes
- No
Please list the types and estimate sizes*
Do they have a history of jumping or biting?*
- Yes
- No
Is there a location for therapy?*
- Yes
- No
Where is the therapy location?*
Is the way to the therapy location free of clutter?*
If therapy is in the basement ?*
- Yes
- No
Does the basement have a walk out exit?*
- Yes
- No
Are there any firearms in the home?*
- Yes
- No
Are the firearms locked up and secure?*
- Yes
- No
UntitledWhat types? How many?*
Are there any smoke detectors in the home?*
- Yes
- No
Do the smoke detectors work?*
- Yes
- No
Are there any carbon monoxide detectors?*
- Yes
- No
Do the carbon monoxide detectors work?*
- Yes
- No
Is there a fire extinguisher(s)?*
- Yes
- No
UntitledWhere is the location of the fire extinguisher(s)?*
Is there a disaster location in the home?*
- Yes
- No
Where is the disaster location?*
If there are stairs in the home are they free of clutter?*
- Yes
- No
Hand rail on stairs is secure?*
- Yes
- No
Is this a smoke free home?*
- Yes
- No
Is the home well kept and reasonable free of clutter?*
- Yes
- No
Bathrooms are reasonable clean?*
- Yes
- No
Are the exits free and clear?*
- Yes
- No
Location of Front exit(s)?*
Location of Rear exit(s)?*
Location of basement exit(s)?*
Are the exits free and clear?*
- Yes
- No
Doors are easily opened and closed?*
- Yes
- No
Please enter any notes, comments or observations not listed above.*

Is the client a victim of physical abuse?*
- Yes
- No
Comment*
Is the client a victim of sexual abuse?*
- Yes
- No
Comment*
Is the client a victim of neglect or significant maltreatment?*
- Yes
- No
Comment*
Has the client been exposed to domestic violence?*
- Yes
- No
Comment*
Has the client been exposed to excessive violence in the community?*
- Yes
- No
Comment*
Has the client had more than two different primary caretakers in his/her lifetime?*
- Yes
- No
Comment*
Does the client have a history of being oppositional and defiant at home (a history of not following rules set by parents)?*
- Yes
- No
Comment*
Is there any pattern of physical or verbal aggression by the client at home?*
- Yes
- No
Comment*
Is there any family history of criminal behavior?*
- Yes
- No
Comment*
Has the client ever failed a grade?*
- Yes
- No
Comment*
Is the client LD or ED?*
- Yes
- No
Comment*
Has the client ever been suspended out of school more than twice?*
- Yes
- No
Comment*
Has the client ever been expelled from school?*
- Yes
- No
Comment*
Does the client refrain from involvement in school activities or clubs?*
- Yes
- No
Comment*
Does the client have a history of behavior problems at school?*
- Yes
- No
Comment*
Has the client ever held a job?*
- Yes
- No
Comment*
If so, has he/she ever been fired from a job?*
- Yes
- No
Comment*
Has the client ever been hospitalized for psychiatric reasons?*
- Yes
- No
Comment*
Are there any reports or does the client exhibit signs of paranoid thinking?*
- Yes
- No
Comment*
Does the client have a history of fighting (more than 5 fights)?*
- Yes
- No
Comment*
Has the client ever caused someone to be seriously injured from a fight?*
- Yes
- No
Comment*
Has the client ever carried a weapon?*
- Yes
- No
Comment*
Has the client ever been involved with a gang?*
- Yes
- No
Comment*
If the client is male, has he ever hit a female because she made him mad?*
- Yes
- No
Comment*
Is there any information available that indicates that the client is a bully?*
- Yes
- No
Comment*
Is the client manipulative?*
- Yes
- No
Comment*
Is the client pathologically narcissistic?*
- Yes
- No
Comment*
Does the client have a pattern or never taking responsibility for his/her misbehaviors?*
- Yes
- No
Comment*
Does the client lie frequently?*
- Yes
- No
Comment*
Is there any history of animal abuse or torture by the client?*
- Yes
- No
Comment*
Is there any history of fire-setting by the client?*
- Yes
- No
Comment*
Is the peer group that the client spends the most time with criminal or considered a negative influence?*
- Yes
- No
Comment*
Is the client a social misfit or under socialized?*
- Yes
- No
Comment*
Is there any information available that indicates that the client is a bully?*
- Yes
- No
Comment*
Does the client have anger management problems?*
- Yes
- No
Comment*
Is the client extremely impulsive?*
- Yes
- No
Comment*
Has the client been diagnosed with ADHD?*
- Yes
- No
Comment*
Does the client lack remorse?*
- Yes
- No
Comment*
Any suspected current substance abuse issues with the client?*
- Yes
- No
Comment
Any suspected current substance abuse issues with the family?*
- Yes
- No
Comment
Does the client have a history of property crimes?*
- Yes
- No
Comment
Does the client have a history of violent/assaultive crimes?*
- Yes
- No
Comment
Has the client ever been charged with a sexual offense?*
- Yes
- No
Comment
Has the chent ever failed on community supervision or been violated?*
- Yes
- No
Comment
Does the chent have sexual identity issues?*
- Yes
- No
Comment
Does the client have a history of excessive use of pomography/erotica?*
- Yes
- No
Comment
Was the client exposed to erotica at an early age (before 10)?*
- Yes
- No
Comment
Is there any evidence of compulsive sexual behaviors by the client (i.e., excessive masturbation)?*
- Yes
- No
Comment
Have there been complaints of boundary violations and over-familiar touching by the client?*
- Yes
- No
Comment
Does the client have diagnosed mental health issues?*
- Yes
- No
Comment
Does the client have any signs of a thought disorder?*
- Yes
- No
Comment
Does the client take any medication?*
- Yes
- No
Comment
Does the Client have a stable home environment in terms of placement?*
- Yes
- No
Comment
Are the caretaker(s) supportive of intervention services?*
- Yes
- No
Comment
Are the caretaker(s) capable and willing to hold the client accountable?*
- Yes
- No
Comment
Does the client have potential victims in the home?*
- Yes
- No
Comment
If the chent has significant mental health issues, is he/she stable now?*
- Yes
- No
Comment
Is the client on probation?*
- Yes
- No
Comment
Does the client appear to be amenable to treatment?*
- Yes
- No
Comment
Is the client motivated to participate in treatment?*
- Yes
- No
Comment
Are there services available to address the client's issues?*
- Yes
- No
Comment
Does the client have access to a positive support system?*
- Yes
- No
Comment
Does the client do well in school or is he/she involved in school activities?*
- Yes
- No
Comment
Has the client benefited from mental health services in the past?*
- Yes
- No
Comment
Does the chent have a history of compliance with authority?*
- Yes
- No
Comment

Has the client ever been non-compliant with prescribed medications?*
- Yes
- No
Please enter any notes, comments or observations not listed above.*
Has the client ever attempted suicide?*
- Yes
- No
What were the suicidal or homicidal behaviors? Include dates, method and lethality.*
Does the client express any current suicidal or homicidal ideation?*
Does the client/family have a history of substance abuse?*
- Yes
- No
Substance Abuse. If the client has an active alcohol or substance abuse problem, has intervention occurred? If so, provide documentation.*
Substance Abuse. Provide documentation of past and present use of alcohol, nicotine, illicit drugs, prescription drugs and over the counter drugs.*
Does the client have a history of criminal/court involvement?*
- Yes
- No
Legal Issues. Are there any present relevant legal issues of the client and/or family? If yes, please provide a summary.*
Is the client currently sexually active?*
- Yes
- No
Is the client promiscuous in his/her sexual behavior?*
- Yes
- No
Provide sexual behavior history.*
Does the client have any history of sexual offending behavior(s)?*
- Yes
- No
Provide details of the sexual offending behavior(s).*
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Email: info@mynextgentherapy.com
Phone: +1 (517) 721-1313

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About
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Client Home Risk Assessment