Danger to Others Risk Assessment

Client Name

First NameLast Name

Client date of birth

Date

Today's Date

Date

THS Staff completing this form with client

First NameLast Name

If your client states they are having or have had thoughts to harm others please complete this questionnaire to assess level of risk now. Assess your client for danger to others thought process to hurt or kill another person. Ensure when assessing their risk you ask specific questions regarding if they have a plan, intent, and what the thoughts are and towards who.

Have you or are you experiencing thoughts to harm or kill others?

YesNo

Have you in the past hurt someone?

YesNo

Do you have a plan to hurt or kill someone?

YesNo

Do you have any intention to hurt or kill someone?

YesNo

Who do your thoughts tell you to hurt?

Have you thought of how you would hurt that person or people? If yes, how?

Do you have access to a firearm?

YesNo

Do you have access to a weapon?

YesNo

Do you believe you will hurt someone today or in the future?

YesNo

Based on your assessment of risk of client please check the box that best applies. If your client is high risk please ensure you do not let your client leave your site before getting your client help. You may need to call the police/911 to ensure safety. We are mandated reporters so you must get your client help and report the danger to others through a mandated report to police and to the person(s) in danger. You have the requirement to keep the community and client safe. Please reach out to Teri Hourihan or your supervisor directly to know next step if you are unsure.

From People in Crisis (6th ed.), by Lee Ann Hoff ASSAULT & HOMICIDAL DANGER ASSESSMENT TOOL

ASSAULT & HOMICIDAL DANGER ASSESSMENT TOOL

1. No predictable risk of assault or homicide: Has no assaultive or homicidal ideation, urges, or history of same; basically satisfactory support system; social drinker only2. Low risk of assault or homicide: Has occasional assault or homicidal ideation (including paranoid ideas) with some urges to kill; no history of impulsive acts or homicidal attempts; occasional drinking bouts and angry verbal outbursts; basically satisfactory support system3. Moderate risk of assault or homicide: Has frequent homicidal ideation and urges to kill but no specific plan; history of impulsive acting out and verbal outbursts while drinking, on other drugs, or otherwise; stormy relationship with significant others with periodic high-tension arguments4. High risk of homicide: Has homicidal plan; obtainable means; history of substance abuse; frequent acting out against others, but no homicide attempts; stormy relationships and much verbal fighting with significant others, with occasional assaults5. Very high risk of homicide: Has current high-lethal plan; available means; history of homicide attempts or impulsive acting out, plus feels a strong urge to control and “get even” with a significant other; history of serious substance abuse; also with possible high-lethal suicide risk