Guardianship Risk Factors Screening Template
Client Name
Date of Screening
Screener Name
1. Evidence of impaired capacity to understand or communicate?
Yes
No
Unsure
2. Evidence of inability to meet basic needs (food, shelter, medical care)?
Yes
No
Unsure
3. Indications of exploitation, abuse, or neglect?
Yes
No
Unsure
4. Challenging or unsafe living situation?
Yes
No
Unsure
5. Signs of mental health or substance use concerns?
Yes
No
Unsure
6. Frequent hospitalizations or emergency visits?
Yes
No
Unsure
7. Additional Notes / Observations