Social Isolation Risk Scoring for Vulnerable Adults
Client Information
Name
Age
Date
Risk Assessment
Risk Factor
Description
Score
Living Situation
Lives with others (0)
Lives alone (1)
Social Contacts
Multiple weekly (0)
Few/rarely (1)
Mobility
Independent (0)
Limited/assisted (1)
Use of Services
Uses services (0)
Does not use/enrolled (1)
Recent Major Life Events
No (0)
Yes (1)
Total Score:
Notes / Recommendations
Assessor Name