This material contains information and guidance for practice. The information is not legal advice. In many instances it will be your obligation to ensure that an older adult gets legal advice as soon as possible.
All material provided is up to date as of August 31, 2010.
Health care professionals and/or service providers should use this form to document concerns about abuse or neglect of an older adult.
The National Initiative for the Care of the Elderly (NICE) has published user-friendly versions of the following tools:
Name of older adult:______________________________________
Date of Birth: ________________________________
Type of incident:
❍ Risk of abuse
❍ Risk of neglect
Type of abuse or neglect (tick all that apply)
❍ Physical abuse
❍ Financial abuse
❍ Sexual assault
❍ Psychological abuse
❍ Forced confinement
Relationship with suspected abuser (tick all that apply):
❍ Family Member:________________________
❍ Health care professional
❍ Person who lives with older adult
Answer the questions and circle the level of risk:
0 = no risk; 5 = extremely high risk.
How many people does the client interact with in a typical week?
Degree of social isolation of the client: 0 1 2 3 4 5
Does the client live with the suspected abuser? ❍ Yes ❍ No ❍ Sometimes
Is the client dependent on the suspected abuser? ❍ Yes ❍ No ❍ Sometimes
Is the suspected abuser dependent on the client? ❍ Yes ❍ No ❍ Sometimes
Types of dependency between client and suspected abuser(tick all that apply):
❍ Financial ❍ Physical ❍ Emotional ❍ Other
Degree of dependency between client and suspected abuser:
0 1 2 3 4 5
Have there been previous incidents of abuse or neglect?
❍ Yes ❍ No
What is the overall degree of risk to the client?
0 1 2 3 4 5
Plan for intervention or follow-up
❍ Legal advocate/lawyer
❍ Seniors’ organization
❍ Social worker
❍ Doctor or specialist
❍ Home support
Who completed this form?
This project has been supported by the Public Health Agency of Canada through the Federal Elder Abuse Initiative. The views expressed herein do not necessarily reflect the official views of the Public Health Agency of Canada.