Abuse Liability Assessment Questionnaire Form
Use this form to assess abuse liability risk, document observed behaviors, and record follow-up actions for the Abuse Liability Assessment Questionnaire.
Assessment Details
Subject / Case ID
*
Assessment Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Assessor / Reviewer Name or Role
*
Assessment Context / Source of Concern
*
Routine review
Incident report
Self-report
Referral
Observed behavior
Other
Behavior and Risk Evaluation
Observed Behavior Frequency
*
Never
Rarely
Sometimes
Often
Very Often
Severity of Incidents
*
Mild
1
2
3
4
5
6
7
8
9
Severe
10
1 is Mild, 10 is Severe
Potential for Escalation
*
Low
1
2
3
4
5
6
7
8
9
High
10
1 is Low, 10 is High
Verbal Aggression Present?
*
No
Yes
Physical Aggression Present?
*
No
Yes
Threat Level
*
Minimal
1
2
3
4
5
6
7
8
9
Extreme
10
1 is Minimal, 10 is Extreme
Triggers and Patterns Observed
Impact and Follow-up
Impact on Others or Environment
*
No known impact
Minor disruption
Property damage
Emotional distress
Safety concern
Environmental impact
Other
Immediate Risk Management Action Taken
*
Monitoring initiated
Temporary restrictions applied
Escalated to supervisor
Emergency services contacted
Removed from situation
No immediate action
Other
Recommended Follow-up Plan
*
Overall Liability Concern Level
*
Low concern
1
2
3
4
5
6
7
8
9
High concern
10
1 is Low concern, 10 is High concern
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