Template library · Assessments & screeners
Child / Elder Safety Screen template
Screen for indicators of abuse, neglect, or unsafe caregiving conditions.
Screen for dependent adult or child safety concerns
- 16 fields across 4 sections
- Included with MyWellOps
- Edit it, or save your own version
What’s in it
Assessment Details
- Client NameText
- Date of BirthDate
- Client ID / MRNText
- Date of AssessmentDate
- Clinician / CoachText
- Location / ModalityText
Safety Indicators
- Unexplained injuries observedTick box
- Signs of neglect (hygiene, nutrition, medical care)Tick box
- Caregiver appears overwhelmed or unable to copeTick box
- Child/dependent reports fear of a caregiverTick box
- History of prior reports or interventionsTick box
- Access to appropriate supervisionTick box
Mandatory Reporting Notes
- Details supporting or ruling out a reportText
- Actions takenText
Signatures
- Clinician SignatureSignature
- Date signed (clinician)Date
When to use it
Use an assessment at the start of work to set a baseline, then repeat it at review points so you and the client can see what has changed.
How it works in MyWellOps
- Pick it from Documents.
- Send it to the client to complete, or fill it in together during a session.
- Each completed copy is kept on the client’s record, so earlier results are there to compare.
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