Vulnerable Adult Substance Misuse Risk Assessment

Personal Information

Name: Date of Birth: Assessment Date: Assessor Name:

Substance Use Details

Type(s) of Substance(s) Used: Frequency of Use: Duration of Use: Route of Administration:

Physical/Mental Health

Physical Health Concerns: Mental Health Concerns: Current Medications:

Risk Assessment

Risk Factor	Details	Present?
Self-Neglect		Yes No
Exploitation		Yes No
Physical Health Deterioration		Yes No
Risk to Others		Yes No
Housing Issues		Yes No
Financial Issues		Yes No

Protective Factors

Summary & Next Steps

Summary of Risks Identified: Actions to Reduce Risk / Support Required: