Homicide/Violence Lethality Assessment

Patient First Name

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Patient Last Name

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A. Currently is there? Violent Threats? And Plans to Harm? Denies, or if yes; describe:

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B. Homicidal Ideation? Denies; or if yes; describe:

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C. History of violent behavior? Denies; or if yes describe:

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D. Preoccupation with lethal weapons? Denies, or if yes describe:

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E. Any current conflicts with other? Denies, or if yes describe:

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F. Any prior arrest for violence? Denies, or if yes describe:

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G. Any charges still pending? Denies, or if yes describe:

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H. Current Homicidal/Violence Risk:

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Evaluator’s Signature/Credentials

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Date

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