Risk Assessment and Safety Planning Note

Risk Assessment and Safety Planning Note Presenting Concerns and Risk Indicators: [Describe current behaviours, thoughts, statements, or symptoms suggesting risk to self or others, including suicidal ideation, threats of harm, emotional distress, escalating behaviour, or increased substance use. Also include contextual risk (e.g. recent trauma, GBV, loss, housing or food insecurity) if relevant.] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) History of Risk Behaviours: [Include any known history of self-harm, suicidal ideation or attempts, aggression, trauma exposure, psychiatric admissions, domestic violence (as victim or perpetrator), or substance-related high-risk incidents.] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Protective Factors and Strengths: [Document any known protective factors such as family or community support, engagement in services, coping skills, religious or cultural beliefs, motivation to recover, parenting responsibilities, or good insight.] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Current Risk Assessment: [State level of assessed risk (e.g. low, moderate, high) and whether there is imminent danger. Include rationale based on behaviour, history, current mental state, and any expressed intent or access to means.] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Safety Plan Components: [Summarise collaboratively agreed steps to reduce risk. This may include:] - [Removing access to means (e.g. weapons, medication)] - [Emergency contacts such as family or community leaders] - [Agreements around supervision or not being alone] - [Engagement with religious or cultural support networks] - [Use of helplines, mental health walk-ins, or nearby clinic services] - [Distraction or grounding techniques discussed] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Referral or Escalation of Care: [Note if emergency services (EMS), SAPS, psychiatric crisis team, social worker, or family were contacted or involved. Include if any transfer to hospital or psychiatric assessment was arranged.] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Follow-up Plan: [Outline the next steps in care, time frame for follow-up contact or review, and agreed monitoring strategies (e.g. clinic appointment, telephonic check-in, school follow-up).] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) (Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care – use only the transcript, contextual notes, or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes, or clinical note, you must not state that the information has not been explicitly mentioned in your output; just leave the relevant placeholder or section blank if not explicitly mentioned. Use as many lines, paragraphs or bullet points as needed to capture all the relevant information from the transcript.)