Appendix 1 Client Name * First Name Last Name Client Number (if known) Assessment Undertaken By: First Name Last Name Is the person known to the service? Y/N (Please add any relevant notes) Is there will be anyone at the residence known to be aggressive, violent or disturbed? Y/N (Please add any relevant notes) Will the Client (or anyone else present) be under the influence of alcohol or drugs during the visit? Y/N (Please add any relevant notes) Will the service be provided outside normal working hours? Y/N (Please add any relevant notes) Do you have any medical condition or disability that we should be aware of? Y/N (Please add any relevant notes) Are there any weapons in the home (if yes, is there a licence and are the weapons stored correctly - in a locked cabinet) Y/N (Please add any relevant notes) Are there any pets? If yes, can the pets be kept in a separate area during the visit? Y/N (Please add any relevant notes) Does anyone at the premises smoke? Y/N (Please add any relevant notes) Are others expected to be present at the time of the visit? Y/N (Please add any relevant notes) Is the client/carer aware of the proposed visit? Y/N (Please add any relevant notes) Has the client/carer consented to the visit? Y/N (Please add any relevant notes) Do you have any cultural or religious preferences (Male/Female only, no visits on Saturdays)? Y/N (Please add any relevant notes) Do you have any sharps in the residence. If yes, do you have an appropriate sharps disposal container? Y/N (Please add any relevant notes) Accommodation details, Type (house/flat) (Please add any relevant notes) Are there any issues with mobile phone coverage in your area? Y/N (Please add any relevant notes) Are the premises easily accessible from the street? Y/N (Please add any relevant notes) Will someone be able to open the door for the visit? Y/N (Please add any relevant notes) Which door is to be used for entry? (Please add any relevant notes) Are there stairs? Y/N Are the stairs/pathway in good condition? Y/N (Please add any relevant notes) Should a visit occur outside daylight hours, is there operational external lighting system for hallways/driveway? Y/N (Please add any relevant notes) Date of Assessment MM DD YYYY Thank you!