Elder Abuse Risk Screening Form
Name
Date of Birth
Date of Assessment
Assessor Name
Is there evidence or suspicion of any of the following?
Physical Abuse
Emotional/Psychological Abuse
Financial Abuse
Sexual Abuse
Neglect
Other
Does the individual depend on others for care?
Yes
No
Is the caregiver under stress or lacking support?
Yes
No
Does the individual show signs of isolation?
Yes
No
Are there unexplained injuries or changes in behavior?
Yes
No
Does the individual have any cognitive impairment?
Yes
No
Additional Concerns or Comments