Position

Company

Phone

Mobile

Email

Relationship with the Client: --None-- Friend Family Coworker Father Mother Parent Son Daughter Child Aunt Uncle Husband Wife Partner Cousin Grandmother Grandfather Grandson Granddaughter Grandchild Employer Employee Guardian Other Family Member

Date of Birth:

Gender: --None-- Male Female Transgender Agender Bi-gender Non-binary Self-described gender identity Prefer not to say

Next of Kin/Partner's Name:

Next of Kin/Partner contact details:

Children:

Client's Phone:

Street

City

Zip

State/Province

Cultural Identity:

English Literacy:

Interpreter Required: --None-- Yes No

Interpreter Details:

Living Arrangements: --None-- Living Alone Living with Others Living with Family

Employment Status: --None-- Employed FT/PT/CAS Unemployed Child not at school Student Home duties Retired Pensioner Other

Alcohol and other drug use:

Mental state/diagnosis:

Current mental health care plan?: --None-- Yes No

Current medications:

Known allergies:

Pregnancy/breastfeeding:

Seizure history:

Disability:

Relevant medical history:

Current Risk Factors: Aggression/violence Domestic violence Harm to others Physical health Self-harm Self-harm/suicide attempt Suicide ideation Vulnerability Other

Current Risk Factor Details:

Previous History of Risk: Aggression/violence Domestic violence Harm to others Physical health Self-harm Self-harm/suicide attempt Suicide ideation Vulnerability Other

Previous History of Risk Details:

Legal Status:

Other services involved:

Consent to gather information:

Reason for Referral:

Client Consent to Referral: --None-- Yes No