Violence Risk Assessment Checklist
Complete this checklist to evaluate the risk factors and protective factors related to potential violence. Please answer each section as accurately as possible.
Person Being Assessed - Full Name
*
First Name
Last Name
Date of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Relationship to Person Being Assessed
*
Self
Family Member
Friend
Healthcare Professional
Law Enforcement
Other
Context or Reason for Assessment
*
Risk Factor Checklist
*
Rows
Not Present
Possible
Present
History of violent behavior
1
2
3
Current threats or plans of violence
4
5
6
Access to weapons
7
8
9
Substance abuse or intoxication
10
11
12
Recent loss or major stressor
13
14
15
Mental health issues
16
17
18
Non-compliance with treatment
19
20
21
Impulsivity or poor self-control
22
23
24
Protective Factors Checklist
*
Rows
Not Present
Possible
Present
Strong social support
25
26
27
Stable living situation
28
29
30
Engaged in treatment
31
32
33
Willingness to seek help
34
35
36
Positive coping strategies
37
38
39
Overall Risk Rating
*
Low
Moderate
High
Recommended Actions
*
No immediate action required
Increase observation or supervision
Refer for psychiatric evaluation
Notify law enforcement
Other
Additional Comments or Observations
Assessor's Full Name
*
First Name
Last Name
Assessor's Role or Position
*
Assessor's Email Address
*
example@example.com
Submit Assessment
Should be Empty: