[Adult
Day Services Center/Program Name]
ELOPEMENT RISK ASSESSMENT
Client: _____________________________________ Date: _________________
Check all that apply:
1.
Orientation:
2.
Behavior:
3.
Ambulation:
4.
Exit Seeking Behaviors: *
5.
“At Risk” Status:
If participant scores on any
starred (*) items in question 1, 2, or 3, AND any item in #4, they are to be
considered at risk for elopement.
6.
Client is “At Risk” for Elopement
7.
If yes:
Social Worker /
Nursing Signature: __________________________ Date:
________________