Harmless Out of Hours Service - Pre-assessment

Welcome!

Harmless' Out of Hours Service is here to help people who are experiencing a crisis.

We want to ensure we can support you in the best way possible and by filling in this form, it helps us to make sure we have all the information to do that and helps us make sure we can keep you safe. It will take around 10 minutes to complete and then we can look at how we can support you tonight. If you'd prefer, you can give us a call and we can have a conversation with you, we still need to ask a few standardised questions before support is offered.

If you would like to do this over the phone with a member of staff please ring - 07925584716

We are unable to accept someone to the out of hours service without this being completed. But it really is so that we can do our best for you and so that we can agree what we can do to help.

This might be that we can support you remotely, by phone or chat, or that we can see you face to face.

Please note: Harmless hosts its out of hours service on Thursdays in East Leake.

What you can expect of us and what we will expect of you: Our Charter

Our out of hours services offers a relaxed environment for those in mental health crisis to work alongside staff to develop solutions and positive outcomes to their current distress.

This space aims to provide a sense of hope and safety ensuring that you receive appropriate advice and guidance to best meet your needs.

Whilst in the service we ask that you treat others and the environment with respect.

We will work alongside you to develop solutions and play an active part in your crisis management planning.

Whilst in our service we ask that visitors refrain from self-harm. We are a place to come to move forwards and it is important that you use the time with us to get the best possible support. Any self-harm on-site would require a review and it may be considered that the service can no longer support you at this time.

Anyone using or threatening violent/intimidating behaviour will be asked to leave.

The Police may be informed of any criminal activity and will carry out their own investigation.

To ensure a safe space for everyone, no animals/pets are allowed in the cafes with the exception of assistance animals.

Carers are welcome to attend with you.

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* 1. Today's date

Date / Time

Date

Time

AM/PM

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* 2. Is this an agency referral

EMAS

Notts Police

111

Crisis Team

CMHT

Third sector service

No, this is a self referral

Other (please specify)

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* 3. Name and contact details of referrer
(skip this question if not applicable)

Name

Company

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

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* 4. Personal details of the person needing help

Name *

Address *

Address 2

City/Town *

ZIP/Postal Code *

Email Address *

Phone Number *

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* 5. Is the person at their place of residence at present?

Yes

If not please specify the address where they will be when we make contact with them?

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* 6. Date of Birth of person needing help

Date

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* 7. Gender

Male

Female

Other (please specify)

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* 8. Ethnicity

White

Mixed / Dual Background

Asian or Asian British

Black or Black British

Chinese

Any Other Ethnic Group

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* 9. What is your sexual orientation?

Asexual

Bisexual

Gay

Heterosexual or straight

Lesbian

Pansexual

Queer

None of the above, please specify

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* 10. What is the employment status of the person needing help?

Retired

Employed - Full Time

Employed - Part Time

Self-Employed

Full-Time Homemaker

Volunteer

Unemployed

Full-Time Student

Part-Time Student

Employed - On Benefits

Unemployed - On Benefits

Employed - On Allowances

Unemployed - On Allowances

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* 11. Next of kin details

Name *

Address *

Address 2

City/Town *

State/Province

ZIP/Postal Code *

Phone Number *

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* 12. Do we have permission to make contact with them? **We will only breach confidentiality without your consent if there is imminent risk to you or someone else. For more details, please ask.

Yes

If there are any circumstances that you don't want this please specify

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* 13. Has the person needing help been using alcohol in the last three hours?

Yes

If yes please specify

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* 14. Has the person needing help been using substances in the last three hours?

Yes

If yes please specify

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* 15. Does the person needing help have any history of violence towards others?

Yes

If yes, please provide details:

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* 16. Do you have a mental health diagnosis/difficulty?

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* 17. Do you have a physical health diagnosis/difficulty?

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* 18. Please answer the following questions on a scale of 0 to 10 where 0 is not at all and 10 is a lot. If the question is not relevant to you then the answer will be '0'.

	0	1	2	3	4	5	6	7	8	9	10
1. I am thinking about hurting myself?	1. I am thinking about hurting myself? 0	1. I am thinking about hurting myself? 1	1. I am thinking about hurting myself? 2	1. I am thinking about hurting myself? 3	1. I am thinking about hurting myself? 4	1. I am thinking about hurting myself? 5	1. I am thinking about hurting myself? 6	1. I am thinking about hurting myself? 7	1. I am thinking about hurting myself? 8	1. I am thinking about hurting myself? 9	1. I am thinking about hurting myself? 10
2. I am planning on hurting myself?	2. I am planning on hurting myself? 0	2. I am planning on hurting myself? 1	2. I am planning on hurting myself? 2	2. I am planning on hurting myself? 3	2. I am planning on hurting myself? 4	2. I am planning on hurting myself? 5	2. I am planning on hurting myself? 6	2. I am planning on hurting myself? 7	2. I am planning on hurting myself? 8	2. I am planning on hurting myself? 9	2. I am planning on hurting myself? 10
3. I am thinking about ending my life	3. I am thinking about ending my life 0	3. I am thinking about ending my life 1	3. I am thinking about ending my life 2	3. I am thinking about ending my life 3	3. I am thinking about ending my life 4	3. I am thinking about ending my life 5	3. I am thinking about ending my life 6	3. I am thinking about ending my life 7	3. I am thinking about ending my life 8	3. I am thinking about ending my life 9	3. I am thinking about ending my life 10
4. I am making a plan to end my life	4. I am making a plan to end my life 0	4. I am making a plan to end my life 1	4. I am making a plan to end my life 2	4. I am making a plan to end my life 3	4. I am making a plan to end my life 4	4. I am making a plan to end my life 5	4. I am making a plan to end my life 6	4. I am making a plan to end my life 7	4. I am making a plan to end my life 8	4. I am making a plan to end my life 9	4. I am making a plan to end my life 10
5. I am able to tolerate my distress	5. I am able to tolerate my distress 0	5. I am able to tolerate my distress 1	5. I am able to tolerate my distress 2	5. I am able to tolerate my distress 3	5. I am able to tolerate my distress 4	5. I am able to tolerate my distress 5	5. I am able to tolerate my distress 6	5. I am able to tolerate my distress 7	5. I am able to tolerate my distress 8	5. I am able to tolerate my distress 9	5. I am able to tolerate my distress 10
6. I am able to tolerate my thoughts	6. I am able to tolerate my thoughts 0	6. I am able to tolerate my thoughts 1	6. I am able to tolerate my thoughts 2	6. I am able to tolerate my thoughts 3	6. I am able to tolerate my thoughts 4	6. I am able to tolerate my thoughts 5	6. I am able to tolerate my thoughts 6	6. I am able to tolerate my thoughts 7	6. I am able to tolerate my thoughts 8	6. I am able to tolerate my thoughts 9	6. I am able to tolerate my thoughts 10
7. I feel positive about my relationships with your friends and family	7. I feel positive about my relationships with your friends and family 0	7. I feel positive about my relationships with your friends and family 1	7. I feel positive about my relationships with your friends and family 2	7. I feel positive about my relationships with your friends and family 3	7. I feel positive about my relationships with your friends and family 4	7. I feel positive about my relationships with your friends and family 5	7. I feel positive about my relationships with your friends and family 6	7. I feel positive about my relationships with your friends and family 7	7. I feel positive about my relationships with your friends and family 8	7. I feel positive about my relationships with your friends and family 9	7. I feel positive about my relationships with your friends and family 10
8. I feel positive about my daily activities (e.g. school or work)	8. I feel positive about my daily activities (e.g. school or work) 0	8. I feel positive about my daily activities (e.g. school or work) 1	8. I feel positive about my daily activities (e.g. school or work) 2	8. I feel positive about my daily activities (e.g. school or work) 3	8. I feel positive about my daily activities (e.g. school or work) 4	8. I feel positive about my daily activities (e.g. school or work) 5	8. I feel positive about my daily activities (e.g. school or work) 6	8. I feel positive about my daily activities (e.g. school or work) 7	8. I feel positive about my daily activities (e.g. school or work) 8	8. I feel positive about my daily activities (e.g. school or work) 9	8. I feel positive about my daily activities (e.g. school or work) 10
9. I feel positive about the future	9. I feel positive about the future 0	9. I feel positive about the future 1	9. I feel positive about the future 2	9. I feel positive about the future 3	9. I feel positive about the future 4	9. I feel positive about the future 5	9. I feel positive about the future 6	9. I feel positive about the future 7	9. I feel positive about the future 8	9. I feel positive about the future 9	9. I feel positive about the future 10
10. I am in a mental health crisis	10. I am in a mental health crisis 0	10. I am in a mental health crisis 1	10. I am in a mental health crisis 2	10. I am in a mental health crisis 3	10. I am in a mental health crisis 4	10. I am in a mental health crisis 5	10. I am in a mental health crisis 6	10. I am in a mental health crisis 7	10. I am in a mental health crisis 8	10. I am in a mental health crisis 9	10. I am in a mental health crisis 10
11. I am in a suicide crisis	11. I am in a suicide crisis 0	11. I am in a suicide crisis 1	11. I am in a suicide crisis 2	11. I am in a suicide crisis 3	11. I am in a suicide crisis 4	11. I am in a suicide crisis 5	11. I am in a suicide crisis 6	11. I am in a suicide crisis 7	11. I am in a suicide crisis 8	11. I am in a suicide crisis 9	11. I am in a suicide crisis 10
12. I am likely to harm myself (without intervention)	12. I am likely to harm myself (without intervention) 0	12. I am likely to harm myself (without intervention) 1	12. I am likely to harm myself (without intervention) 2	12. I am likely to harm myself (without intervention) 3	12. I am likely to harm myself (without intervention) 4	12. I am likely to harm myself (without intervention) 5	12. I am likely to harm myself (without intervention) 6	12. I am likely to harm myself (without intervention) 7	12. I am likely to harm myself (without intervention) 8	12. I am likely to harm myself (without intervention) 9	12. I am likely to harm myself (without intervention) 10
13. I am likely to harm someone else (without intervention)	13. I am likely to harm someone else (without intervention) 0	13. I am likely to harm someone else (without intervention) 1	13. I am likely to harm someone else (without intervention) 2	13. I am likely to harm someone else (without intervention) 3	13. I am likely to harm someone else (without intervention) 4	13. I am likely to harm someone else (without intervention) 5	13. I am likely to harm someone else (without intervention) 6	13. I am likely to harm someone else (without intervention) 7	13. I am likely to harm someone else (without intervention) 8	13. I am likely to harm someone else (without intervention) 9	13. I am likely to harm someone else (without intervention) 10
14. I am in distress	14. I am in distress 0	14. I am in distress 1	14. I am in distress 2	14. I am in distress 3	14. I am in distress 4	14. I am in distress 5	14. I am in distress 6	14. I am in distress 7	14. I am in distress 8	14. I am in distress 9	14. I am in distress 10
15. I am likely to consume alcohol	15. I am likely to consume alcohol 0	15. I am likely to consume alcohol 1	15. I am likely to consume alcohol 2	15. I am likely to consume alcohol 3	15. I am likely to consume alcohol 4	15. I am likely to consume alcohol 5	15. I am likely to consume alcohol 6	15. I am likely to consume alcohol 7	15. I am likely to consume alcohol 8	15. I am likely to consume alcohol 9	15. I am likely to consume alcohol 10
16. I am likely to consume substances	16. I am likely to consume substances 0	16. I am likely to consume substances 1	16. I am likely to consume substances 2	16. I am likely to consume substances 3	16. I am likely to consume substances 4	16. I am likely to consume substances 5	16. I am likely to consume substances 6	16. I am likely to consume substances 7	16. I am likely to consume substances 8	16. I am likely to consume substances 9	16. I am likely to consume substances 10
17. I am likely to behave recklessly	17. I am likely to behave recklessly 0	17. I am likely to behave recklessly 1	17. I am likely to behave recklessly 2	17. I am likely to behave recklessly 3	17. I am likely to behave recklessly 4	17. I am likely to behave recklessly 5	17. I am likely to behave recklessly 6	17. I am likely to behave recklessly 7	17. I am likely to behave recklessly 8	17. I am likely to behave recklessly 9	17. I am likely to behave recklessly 10
18. I feel safe	18. I feel safe 0	18. I feel safe 1	18. I feel safe 2	18. I feel safe 3	18. I feel safe 4	18. I feel safe 5	18. I feel safe 6	18. I feel safe 7	18. I feel safe 8	18. I feel safe 9	18. I feel safe 10
19. I am unable to cope	19. I am unable to cope 0	19. I am unable to cope 1	19. I am unable to cope 2	19. I am unable to cope 3	19. I am unable to cope 4	19. I am unable to cope 5	19. I am unable to cope 6	19. I am unable to cope 7	19. I am unable to cope 8	19. I am unable to cope 9	19. I am unable to cope 10
20. I feel hopeless	20. I feel hopeless 0	20. I feel hopeless 1	20. I feel hopeless 2	20. I feel hopeless 3	20. I feel hopeless 4	20. I feel hopeless 5	20. I feel hopeless 6	20. I feel hopeless 7	20. I feel hopeless 8	20. I feel hopeless 9	20. I feel hopeless 10

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* 19. If you are unable to get help from Harmless' Out of Hours Service, what do you think will happen?

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* 20. If you are unable to get help from Harmless' Out of Hours Service where else will you look for support, or what services will you use?

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* 21. We offer remote support with some face to face availability, what is your preference?

Telephone call

Video call

Text chat

Face to face appointment

Group support

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* 22. Do you have any dependents at home?

Yes

If yes, please specify:

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* 1. Today's date

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* 2. Is this an agency referral

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* 3. Name and contact details of referrer(skip this question if not applicable)

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* 4. Personal details of the person needing help

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* 5. Is the person at their place of residence at present?

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* 6. Date of Birth of person needing help

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* 7. Gender

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* 8. Ethnicity

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* 9. What is your sexual orientation?

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* 10. What is the employment status of the person needing help?

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* 11. Next of kin details

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* 12. Do we have permission to make contact with them? **We will only breach confidentiality without your consent if there is imminent risk to you or someone else. For more details, please ask.

Question Title

* 13. Has the person needing help been using alcohol in the last three hours?

Question Title

* 14. Has the person needing help been using substances in the last three hours?

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* 15. Does the person needing help have any history of violence towards others?

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* 16. Do you have a mental health diagnosis/difficulty?

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* 17. Do you have a physical health diagnosis/difficulty?

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* 18. Please answer the following questions on a scale of 0 to 10 where 0 is not at all and 10 is a lot. If the question is not relevant to you then the answer will be '0'.

Question Title

* 19. If you are unable to get help from Harmless' Out of Hours Service, what do you think will happen?

Question Title

* 20. If you are unable to get help from Harmless' Out of Hours Service where else will you look for support, or what services will you use?

Question Title

* 21. We offer remote support with some face to face availability, what is your preference?

Question Title

* 22. Do you have any dependents at home?

* 3. Name and contact details of referrer
(skip this question if not applicable)