Preliminary Risk Assessment Form
Full Name of NDIS Participant
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First Name
Last Name
Gender?
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Male
Female
Non-Binary
NDIS DIAGNOSIS
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Mobility:
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Good to Fair - Good to fair mobility (eg I am able to get up, into the bathroom and start my day without the use of aids; If I needed to, I could walk a short distance to the local shops for groceries)
Use aids to support themselves, occasional wheelchair use.
High risk of falling, multiple falls in the last 6 months, wheelchair bound, seizures & tremors.
Any falls in the last 6 months
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Yes
No
Further details
Independance in daily life
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Yes
No
Further details
Can easily navigate new experiences
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Yes
No
Further details
Experiences fatigue
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Yes
No
Further details
Experiences anxiety in public spaces and with new people
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Yes
No
Further details
Triggers - Psychosocial & Environmental
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Low
Med
High
Further details
Help with preparing food/meals
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Yes
No
Further details
Personal Care Requirements
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None
Support with showering & dressing
High personal support needs - showering/dressing/toileting
Further details
Diagnosis Specifics
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Has Psycho-Social &/or Multiple Diagnosis (med & high)
Suicidal Ideation & Self Harm - post or present (med & high - make current assessment)
Schizophrenia/ Schizoaffective Disorder (high)
Current/recent Psychosis, Auditory and/or Visual Hallucinations (high)
Motor Neuron Disease (high)
Traumatic/acquired Brain Injury (high)
Advanced Dementia (high)
Epilepsy (med & high - make current assessment)
History of Alcoholism &/or Drug Use (med - high - make current assessment)
Parkinson's Diagnosis (high)
None of these apply
Further details
Final Analysis
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Low (No Risk & Care Assessment required)
Med (Review only Risk & Care Assessment required)
High (Detailed Risk & Care Assessment required & OT Assessment)
Summary of Final Analysis. (Consider: Level of support required. Accommodation requirements. Travel requirements. Mobility Aids required)
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Name of person who conducted this assessment
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