Template library · Assessments & screeners
Environmental Safety Checklist template
Assess the client's physical environment for safety hazards.
Review of physical/home environment safety
- 15 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
Environmental Factors
- Firearms or weapons in the homeTick box
- Medications stored securelyTick box
- Alcohol or substances readily accessibleTick box
- Stable housing situationTick box
- Adequate heat, water, and utilitiesTick box
- Home is free of unsafe structural conditionsTick box
Notes
- Recommended environmental modificationsText
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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