Template library · Assessments & screeners
Self-Harm Risk Assessment template
Evaluate history and current risk of self-harming behavior.
Structured assessment of non-suicidal self-injury risk
- 19 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
History & Current Risk
- Current urge to self-harmTick box
- History of self-harmTick box
- Method(s) used previouslyTick box
- Access to meansTick box
- Function of self-harm identified (regulation, communication, etc.)Tick box
- Recent escalation in frequency or severityTick box
Safety Plan
- Coping strategies to use insteadText
- Support contactsText
- Means restriction steps takenText
Signatures
- Clinician SignatureSignature
- Date signed (clinician)Date
- Client SignatureSignature
- Date signed (client)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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