Client Home Risk Assesment – Pavo Behavioral Therapy

Client Home Risk Assessment

Step 1 of 3

33%

Client Name(Required)

Date of risk assessment(Required)

Address the risk assessment was performed?(Required)

Are there multiple therapy locations?(Required)

Yes

Are there pets?(Required)

Yes

Please list the types and estimate sizes

Do the pets have a history of jumping or biting?

Yes

Is there a location for therapy?(Required)

Yes

Where is the therapy space located?(Required)

Is the way to the therapy space free of clutter?(Required)

Is the therapy space in a basement?(Required)

Yes

If so, does the basement have a walk out exit?

Yes

Are there any firearms in the home?(Required)

Yes

If so, are the firearms locked up and secure?

Yes

What types? How many?(Required)

Are there any smoke detectors in the home?(Required)

Yes

Do the smoke detectors work?(Required)

Yes

Are there any carbon monoxide detectors?(Required)

Yes

Do the carbon monoxide detectors work?(Required)

Yes

Is there a fire extinguisher(s)?(Required)

Yes

Where is the location of the fire extinguisher(s)?(Required)

Is there a disaster location in the home?(Required)

Yes

Where is the disaster location?

If there are stairs in the home are they free of clutter?(Required)

Yes

Hand rail on stairs is secure?(Required)

Yes

Is this a smoke free home?(Required)

Yes

Is the home well kept and reasonably free of clutter?(Required)

Yes

Are the bathrooms reasonably clean?(Required)

Yes

Are the exits free and clear?(Required)

Yes

Location of Front exit(s)?(Required)

Location of Rear exit(s)?(Required)

Location of basement exit(s)?

Are the doors easily opened and closed?(Required)

Yes

Please enter any notes, comments or observations not listed above.

Is the client a victim of physical abuse?(Required)

Yes

Comment

Is the client a victim of sexual abuse?(Required)

Yes

Comment

Is the client a victim of neglect or significant maltreatment?(Required)

Yes

Comment

Has the client been exposed to domestic violence?(Required)

Yes

Comment

Has the client been exposed to excessive violence in the community?(Required)

Yes

Comment

Has the client had more than two different primary caretakers in his/her lifetime?(Required)

Yes

Comment

Does the client have a history of being oppositional and defiant at home (a history of not following rules set by parents)?(Required)

Yes

Comment

Is there any pattern of physical or verbal aggression by the client at home?(Required)

Yes

Comment

Is there any family history of criminal behavior?(Required)

Yes

Comment

Has the client ever failed a grade?(Required)

Yes

Comment

Does the child have a learning disability or an emotional disorder?(Required)

Yes

Comment

Has the client ever been suspended from school more than twice?(Required)

Yes

Comment

Has the client ever been expelled from school?(Required)

Yes

Comment

Does the client refrain from involvement in school activities or clubs?(Required)

Yes

Comment

Does the client have a history of behavior problems at school?(Required)

Yes

Comment

Has the client ever held a job?(Required)

Yes

Comment

If so, has he/she ever been fired from a job?(Required)

Yes

Comment

Has the client ever been hospitalized for psychiatric reasons?(Required)

Yes

Comment

Are there any reports or does the client exhibit signs of paranoid thinking?(Required)

Yes

Comment

Does the client have a history of fighting (more than 5 fights)?(Required)

Yes

Comment

Has the client ever caused someone to be seriously injured from a fight?(Required)

Yes

Comment

Has the client ever carried a weapon?(Required)

Yes

Comment

Has the client ever been involved with a gang?(Required)

Yes

Comment(Required)

If the client is male, has he ever hit a female because she made him mad?(Required)

Yes

Comment(Required)

Is there any information available that indicates that the client is a bully?(Required)

Yes

Comment

Is the client manipulative?(Required)

Yes

Comment

Is the client pathologically narcissistic?(Required)

Yes

Comment

Does the client have a pattern or never taking responsibility for his/her misbehaviors?(Required)

Yes

Comment

Does the client lie frequently?(Required)

Yes

Comment

Is there any history of animal abuse or torture by the client?(Required)

Yes

Comment

Is there any history of fire-setting by the client?(Required)

Yes

Comment

Is the peer group that the client spends the most time with criminal or considered a negative influence?(Required)

Yes

Comment(Required)

Is the client a social misfit or under socialized?(Required)

Yes

Comment(Required)

Is there any information available that indicates that the client is a bully?(Required)

Yes

Comment(Required)

Does the client have anger management problems?(Required)

Yes

Comment(Required)

Is the client extremely impulsive?(Required)

Yes

Comment(Required)

Has the client been diagnosed with ADHD?(Required)

Yes

Comment(Required)

Does the client lack remorse?(Required)

Yes

Comment(Required)

Any suspected current substance abuse issues with the client?(Required)

Yes

Comment(Required)

Any suspected current substance abuse issues with the family?(Required)

Yes

Comment

Does the client have a history of property crimes?(Required)

Yes

Comment(Required)

Does the client have a history of violent/assaultive crimes?(Required)

Yes

Comment(Required)

Has the client ever been charged with a sexual offense?(Required)

Yes

Comment(Required)

Has the client ever failed on community supervision or been violated?(Required)

Yes

Comment

Does the chent have sexual identity issues?(Required)

Yes

Comment(Required)

Does the client have a history of excessive use of pornography/erotica?(Required)

Yes

Comment(Required)

Was the client exposed to pornography at an early age (before 10)?(Required)

Yes

Comment(Required)

Is there any evidence of compulsive sexual behaviors by the client (i.e., excessive masturbation)?(Required)

Yes

Comment(Required)

Have there been complaints of boundary violations and over-familiar touching by the client?(Required)

Yes

Comment(Required)

Does the client have diagnosed mental health issues?(Required)

Yes

Comment(Required)

Does the client have any signs of a thought disorder?(Required)

Yes

Comment(Required)

Does the client take any medication?(Required)

Yes

Comment(Required)

Does the client have a stable home environment in terms of placement?(Required)

Yes

Comment(Required)

Are the caretaker(s) supportive of intervention services?(Required)

Yes

Comment

Are the caretaker(s) capable and willing to hold the client accountable?(Required)

Yes

Comment(Required)

Does the client have potential victims in the home?(Required)

Yes

Comment(Required)

If the chent has significant mental health issues, is he/she stable now?(Required)

Yes

Comment(Required)

Is the client on probation?(Required)

Yes

Comment(Required)

Does the client appear to be amenable to treatment?(Required)

Yes

Comment(Required)

Is the client motivated to participate in treatment?(Required)

Yes

Comment(Required)

Are there services available to address the client's issues?(Required)

Yes

Comment(Required)

Does the client have access to a positive support system?(Required)

Yes

Comment(Required)

Does the client do well in school or is he/she involved in school activities?(Required)

Yes

Comment(Required)

Has the client benefited from mental health services in the past?(Required)

Yes

Comment(Required)

Does the chent have a history of compliance with authority?(Required)

Yes

Comment(Required)

Has the client ever been non-compliant with prescribed medications?(Required)

Yes

Please enter any notes, comments or observations not listed above.

Has the client ever attempted suicide?(Required)

Yes

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?(Required)

Yes

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?(Required)

Yes

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?(Required)

Yes

Is the client promiscuous in his/her sexual behavior?(Required)

Yes

Provide sexual behavior history.

Does the client have any history of sexual offending behavior(s)?(Required)

Yes

Provide details of the sexual offending behavior(s).

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Client Home Risk Assessment

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