Confidential Elder Abuse Assessment Form

Client Information

Full Name Date of Birth Gender Female Male Other Address Phone Number

Assessment Details

Referrer (if any) Date of Assessment Relationship to Alleged Abuser

Abuse Assessment

Type(s) of Alleged Abuse Physical Emotional Financial Neglect Sexual Other Description of Abuse/Concerns Injury/Physical Signs Observed Risk Level Low Medium High

Actions Taken

Actions Taken/Recommendations Other Agencies Involved

Assessor's Details

Assessor's Name Position/Title Contact Information Signature Date