Mental Health Transport Risk Assessment Form printable pdf download

Mental Health Transport Risk Assessment Form

This form is intended to be used by services in order to identify the following:

Section 1: Assessed by

Section 2: Personal Particulars

Section 3: Risk Assessment Matrix

Section 4: Result of Assessment

THIS FORM IS USED TO ASSESS RISK ASSOCIATED WITH MENTAL HEALTH TRANSPORTATION ONLY AND SHOULD NOT REPLACE

INDIVIDUAL AGENCY OPERATIONAL OR CLINICAL PROTOCOLS.

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.

Referrer’s Name:_______________________________ Contact Number:________________________

Please inform receiving site when the patient departs pick up location. This will ensure necessary resources can be in place to support the

patient admission.

SECTION 1 – Assessed by

Medical or Authorised Practitioner: __________________________________________________

Centre / Clinic / Hospital: ___________________________________________________________

Treated On: ______/_______/_______

SECTION 2 – Personal Particulars

Surname: __________________________ Given Names: _____________________________________

Date of Birth: _______/_______/_______ Language Spoken:_________________________________

Address: _____________________________________________________________________________

Add the patient’s current residential address in this field. If the patient is located at another place, record the address and location in the

notes field supplied in Section 4.

Is the patient currently receiving treatment for a mental illness? Yes ⃝ No ⃝

SECTION 3 – Risk Assessment Matrix

Complete Attachment A

•

Indicate risk for each criterion by placing a tick in the applicable box.

• Each matrix is a tool to record information and provide guidance on a suitable transport option. If the majority

of boxes ticked align to one risk category, the clinician’s informed judgement should be used to determine if this

is the most appropriate risk rating and transport option.

• Reasons for not selecting the risk rating that aligns to the majority of boxes ticked should be recorded in the

Risk Rating Rationale section on the following page.

SECTION 4 – Result of Assessment

Form 4A - Transport Order:

Completed ⃝

Transport Type:

Inter-Hospital ⃝

Community to Hospital ⃝

Transport by:

Mental Health Transport Officer ⃝ Police Officer ⃝

(Metropolitan area only)

NEXT STEPS

1. Identify bed availability (contact local inpatient service Bed Manager or delegate)

2. Book transport with appropriate provider (or refer to WA Police where appropriate)

3. Provide appropriate documentation to transport providers and others involved

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Mental Health Transport Risk Assessment Form

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