Initial Risk Assessment Form - Ability Partners

Incident Risk Assessment Form

To ensure everyone's safety during therapy, we have to confirm the following questions:

Complete the form below for yourself or on behalf of a participant.

"*" indicates required fields

First Name*

Last Name*

Email Address*

Phone Number*

Who are you referring?*

Is there any court orders or alternate parenting arrangements we need to aware of?*

Yes

No

Does the client have any allergies, chronic illness or medical issues we need to be aware of?*

Yes

No

Does the client get overwhelmed in busy environments?*

Yes

No

Does the client have any sensitivities or dislikes we need to be aware of?*

Yes

No

Does the client have difficulty finishing or leaving appointments?*

Yes

No

Does the client ever abscond (run away) or wander?*

Yes

No

Does the client present with unexpected aggressive or violent behaviours?*

Yes

No

Are there any successful strategies that have been identified to manage any of the above mentioned concerns?

Other Comments: