Elopement Risk Assessment & Unauthorized Leave Tracking Form – Home Care, Assisted Living and Group Home Template

Track recurring unauthorized leave, wandering, and elopement incidents with this professional Continuous Unauthorized Leave & Elopement Risk Assessment Template.
Designed for home care agencies, assisted living facilities, memory care programs, group homes, behavioral health programs, and residential care providers, this customizable form provides an organized way to document repeated incidents, identify patterns, assess contributing factors, record previous interventions, and develop an ongoing safety plan.

The template includes 30-, 60-, and 90-day tracking, making it especially useful when a single incident report is not enough to document an ongoing pattern of unauthorized leave or wandering behavior.

WHAT’S INCLUDED
This Continuous Unauthorized Leave Form includes sections for:
• Client / Resident Information
• Elopement & Unauthorized Leave Risk Factors
• 30-Day Incident Tracking
• 60-Day Incident Tracking
• 90-Day Incident Tracking
• Incident History & Documentation
• Most Recent Incident Summary
• Contributing Factors
• Client Condition Assessment
• Risk Level Assessment
• Family / Responsible Party Notifications
• Previous Interventions Attempted
• Current Corrective Action Plan
• Safety Planning
• Supervision Considerations
• Administrative Review
• Continued Monitoring
• Discharge / Transition Considerations
• Signature & Acknowledgment Section

PERFECT FOR
• Home Care Agencies
• Assisted Living Facilities
• Memory Care Programs
• Group Homes
• Residential Care Programs
• Supportive Living Programs
• Behavioral Health Programs
• Adult Residential Facilities
• Senior Care Providers
• Hospice & Healthcare Providers
• Program Administrators
• Care Coordinators
TRACK RECURRING ELOPEMENT & UNAUTHORIZED LEAVE
When unauthorized leave occurs repeatedly, documenting each event individually may not provide a complete picture of the pattern.
This form provides a centralized place to:

✓ Track incidents over 30, 60, and 90 days
✓ Identify recurring patterns
✓ Document the most recent incident
✓ Record contributing factors
✓ Assess changing risk levels
✓ Document family or responsible-party notifications
✓ Record interventions already attempted
✓ Establish corrective actions
✓ Develop an updated safety plan
✓ Document administrative decisions
✓ Maintain organized resident records

ELOPEMENT RISK ASSESSMENT
Use the risk assessment section to document factors that may contribute to recurring wandering or unauthorized leave.
The form can help your organization maintain a written record of the resident or client's current circumstances, incident history, identified concerns, and interventions.

This may be especially useful when supporting individuals who require additional supervision due to cognitive, behavioral, or other care needs.

30 / 60 / 90-DAY INCIDENT TRACKING
Unlike a standard incident report, this template includes dedicated 30-, 60-, and 90-day tracking to help identify recurring patterns over time.
Use this section to maintain a chronological record of incidents and provide staff or administrators with a more complete overview when reviewing the individual's current support and safety needs.

CORRECTIVE ACTION & SAFETY PLANNING
Document what has already been attempted and what changes may be considered going forward.
The template provides space for:

• Previous Interventions
• Current Corrective Actions
• Safety Measures
• Monitoring
• Family / Responsible Party Communication
• Administrative Determination
• Discharge or Transition Planning

The existing form includes administrative options addressing whether services should continue, be monitored, or move toward discharge/transition planning.

CUSTOMIZABLE FOR YOUR ORGANIZATION
Personalize the template with your:
• Agency or facility name
• Logo
• Client / resident information
• Risk assessment procedures
• Incident information
• Intervention strategies
• Safety procedures
• Responsible-party information
• Administrative review procedures
• Program-specific documentation requirements

DIGITAL DOWNLOAD
This is a digital product. No physical item will be shipped.
Your purchase includes 1 PDF and 1 additional digital file.

After purchase, download your files, customize the applicable sections for your organization, and use the template for ongoing unauthorized leave and elopement documentation.

IMPORTANT DISCLAIMER
This template is provided for general administrative, informational, and documentation purposes only and does not constitute medical, behavioral health, legal, licensing, regulatory, or compliance advice.
This form does not replace an individualized clinical assessment, professional elopement risk assessment, care plan, emergency procedure, or other evaluation that must be completed by an appropriately qualified professional.

Organizations are responsible for establishing appropriate supervision, emergency response, notification, incident reporting, discharge, and safety procedures based on the individual's needs and applicable requirements.

Purchasers are responsible for reviewing and customizing the template for their specific services, residents, facility type, and jurisdiction.

Due to the nature of digital products, all sales are final.