Name of young person:

Date of birth:

Date form completed:

Completed by:

Date of birth
Emergency contact (Name, relationship and telephone number)
Address of young person
Email address for correspondence
Allergies
Any other essential information
How will this person travel to and from the farm?

Physical Health	Details of Risk/Management/Containment
Yes	No	DK
No Risks Identified at Initial Assessment
Pain Management Problems
Physical Illness – chronic, acute, recurrent
Previous history of self-neglect
Falling
Epileptic
Diabetic
Visual / hearing impairment
Wheelchair dependent
Issues with medication compliance
Swallowing Problems
Infection e.g., HIV, Hep B, MRSA
Forensic
Criminal convictions – dates, details
Time in special hospital, prison, regional secure unit. locked ward etc. – dates, reports, other details
Sexual Assault
ABH / GBH – Specify
Other forensic criminal activity including stalking, hostage-taking, fire-setting………
Mental Health	Details of Risk/Management/Containment
Yes	No	DK
No Risks Identified at Initial Assessment
Misuse of alcohol / drugs (number, dates, methods especially if violent
Personality change
MHA admissions – dates, details
Bereavement
History of self-harm / suicide incidents – number, dates, methods
Verbal or implied threat of self-harm
Verbal or implied threat of suicide
Depressed, evidence of low mood – chronic, acute, recurrent.
Anxiety – impacting a Daily Living
Considered intent e.g., evidence of planning
Self-harm / suicide perceived as a solution
Psychotic behaviours – Chronic, acute, recurrent
Believe no control over their life, nothing changing
Family history or peer culture of self-harm / suicide

Cognitive / Behavioural	Details of Risk/Management/Containment
Yes	No	DK
No Risks Identified at Initial Assessment
Denies problems perceived by others – specify
Difficulty communicating needs
Compliance – e.g., with contact / treatment /adherence to plans
Frontal lobe injury
Sexually inappropriate behaviours – specify
Deliberate damage to property
Significant cognitive deficit
Wandering
Lack of insight
Verbal Aggression
Physical Aggression
Is there a Mental Capacity Issue - specify
Impulsivity
Emotionally Labile
Memory Issues
Community / Environmental	Details of Risk/Management/Containment
Yes	No	DK
No Risks Identified at Initial Assessment
Previous history of breakdown of relationships with therapy
Social Care Involvement
Driving - Risk as passenger – specify
Difficulty with basic self-care needs e.g. food, dressing, hygiene
Unable to communicate effectively - circumstances
Unsafe / poor use of appliances
Specific fire risks – detail circumstances
Unable to access community activities
Financial difficulties – specify
Abuse / exploitation – detail
Harassment / bullying by others
Dogs/Other animals
Indication for a 2:1 working
Risk of contamination from property or inhabitants
Carer/ relative non-compliant with advice

Sources of information used:
Yes	No
Client
Client’s family/partner
Police
Medical Records (BFW)
Care Staff
Medical Health Records
Other

Summary/ List of Current Risk(s)

List areas where risks are high and unlikely to change, or serious risk

Actions required to minimise risks identified above, and actions that contain risk detailed on screening list over leaf

Assessment completed by:

Date of Completion: Risk Assessment Review Due:

Review Risk Assessment (new information / changes)

Date of Current Assessment:

Summary of New Information / Changes to the above initial assessment

Actions required to minimise risks identified above.

Assessment completed by:

Date of Completion: Risk Assessment Review Due: