Mental Health Transport Risk Assessment Form
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2Mental Health Transport Risk Assessment Form
Mental Health Transport Risk Assessment Form
This form is to be used by services in order to identify the following:
SECTION 1: Assessed by SECTION 2: Personal Particulars SECTION 3: Risk Assessment SECTION 4: Result of Assessment
THIS FORM IS USED TO ASSESS RISK ASSOCIATED WITH MENTAL HEALTH T
THIS FORM IS USED TO ASSESS RISK ASSOCIATED WITH MENTAL HEALTH T
RANSPORTATION ONLY AND
RANSPORTATION ONLY AND
SHOULD NOT REPLACE INDIVIDUAL AGENCY OPERATIONAL OR CLINICAL PRO
TOCOLS.
SHOULD NOT REPLACE INDIVIDUAL AGENCY OPERATIONAL OR CLINICAL PRO
TOCOLS.
The purpose of information sharing is to ensure each agency has sufficient information to enable them to provide effective and appropriate services.
Collection and disclosure should be limited to personal information that is necessary and relevant to these purposes and occur in accordance with
Section 576 and 577 of the Mental Health Act 2014.
SECTION 1
–
MEDICAL or AUTHORISED PRACTITIONER:___________________________
___________
SECTION 1
–
MEDICAL or AUTHORISED PRACTITIONER:___________________________
___________
CENTRE / CLINIC / HOSPITAL:_____________________________________
_____________________
CENTRE / CLINIC / HOSPITAL:_____________________________________
_____________________
TREATED ON:_______
TREATED ON:_______
/_______/_______
/_______/_______
CURRENTLY ON C.T.O:
CURRENTLY ON C.T.O:
YES
NO
Indicate by placing a
or
in either box
FORM NUMBER:_____________________
FORM NUMBER:_____________________
SECTION 2
–
PERSONAL PARTICULARS
SECTION 2
–
PERSONAL PARTICULARS
SURNAME:______________________________ GIVEN NAMES:_____________
SURNAME:______________________________ GIVEN NAMES:_____________
__________________
__________________
DATE OF BIRTH:_______/_______/_______
LANGUAGE SPOKEN:__________________________
DATE OF BIRTH:_______/_______/_______
LANGUAGE SPOKEN:__________________________
ADDRESS:________________________________________________________
ADDRESS:________________________________________________________
_________________
_________________
Add the consumers current residential address in this field. If the consumer is located at another place, record the address and location in the notes field supplied in Section 3.
Is the person currently receiving treatment for a mental illness?
YES
NO
Indicate by placing a
or
in either box
SECTION 3
SECTION 3
RISK ASSESSMENT MATRIX
RISK ASSESSMENT MATRIX
Tick
IMPORTANT: Police will only assist with an Extreme risk category transport.
The Risk Assessment Matrix identifies four categories in which mental health patient transports are conducted. The matrix in
conjunction with additional notes, should assist in deciding the level of risk associated with the transport.
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Parent category: Medical