Clinical Assessment

We usually send letters to your GP about your care, if you are at risk. Select to give consent

Yes No

Would you wish to receive a copy of this information?

Yes No

Who could receive this information

Address to which they would like copies sent (if different from above)

IT Consent - We store your information on a very secure IT system and also in note form, which can only be accessed by members of our department, do you give consent to store information?

Yes No

Have you ever been physically violent towards other people?

Yes No

If yes, give details of most recent incident and dates of any criminal convictions.

Do you ever hurt yourself on purpose? (e.g. cutting, burning, punching yourself)

Yes No

If yes please give brief details and when this last occurred.

When did you first self harm?

When did you first have thoughts of self harm?

Have you ever had thoughts to end your life?

Yes No

When did you first have thoughts of suicide?

When did you first attempt?

Can you give us brief details about the person you lost to suicide?

Are you aware of anyone else that has ended their life?

Yes No

If yes, please give brief details (whenever possible collect same details as above)

Sometimes things happen to people that are extremely upsetting, like being in a major life threatening situation like a major disaster or a serious accident of a fire, being physically assaulted or raped, seeing another person killed or dead, or badly hurt, or hearing something terrible has happened to someone close to you. At any time in your life did any of these things happened to you?

Yes No

If yes, list the events, brief description date, how old was the person when the event occurred?

For some people these things come back in nightmares and flashbacks or thoughts that you cannot get rid of. Has that ever happened to you?

Yes No

If yes, list the events, brief description date, how old was the person when the event occurred?

If No, what about being upset when you were I a situation that reminded you of these things?”

Have you ever had a head injury that caused you to lose consciousness or black out?

Yes No

How long after the injury before you were able to remember normally? (>24 hrs is significant)

Have you noticed any changes in how you go about things or how people behave towards you since the head injury?

Do you regularly experience negative thoughts?

Yes No

Do you currently experience distressing voices telling you to do things?

Yes No

Explore risk in relations to children E.g. do voices involve children?

Do you have any current or ongoing physical health problems?

Describe your sleeping patterns.

Describe your eating pattern.

Describe your caffeine intake.

Describe your smoking habit.

How do you occupy your time?

Risk to Self?

Yes No

If Yes state details

Risk to others?

Yes No

If Yes state details

Risk of Exploitation?

Yes No

If Yes state details of disclosure

Risk of Neglect?

Yes No

If Yes state details of disclosure

Do you drink alcohol?

Yes No

Do you drink an amount that other people are concerned about?

Yes No

How much alcohol have you drunk in the last week? (units)

How many days have you drank alcohol in the last week?

Have you ever taken any d/8rugs including prescribed medication

Yes No

Do you take them now?

Yes No

How much and how often do you take it?

How much are you spending on average per week on drugs?

Financial difficulties /Debt

Do you have any financial or debt issues that impact on your mental health?

Yes No

Clinical Assessment

Harm

PTSD

HEAD INJURY

PSYCHOSIS

Physical health

Alcohol Use

Substance Misuse

Financial difficulties /Debt

Treatment Choice