Safety Planning Tool

Appendix 8.1 – Intake and Risk Assessment Checklist

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Survivor Information

Name or identifier:

Age:

Preferred method of communication:

Date of intake:

Staff member completing intake:

Current jurisdiction:

Safe contact information confirmed:

Emergency contact/support person identified:

Presenting Concern

Type of victimization:

Non-consensual distribution of intimate images

Sextortion

Online luring

Child sexual abuse material (CSAM)

Deepfake/altered imagery

Stalking/harassment

Doxing

Other

Brief description of incident:

Date(s) of occurrence:

Is victimization ongoing?

Yes

Unknown

Risk Assessment Indicators

Content Distribution

Content confirmed online

Unknown distribution status

Public sharing identified

Shared with peers/community

Shared on forums/websites

Personal information attached

Content actively circulating

Emotional and Psychological Functioning

    Acute distress
    Panic/fear
    Shame/humiliation
    Sleep disruption
    Hypervigilance
    Self-harm concerns
    Suicidal ideation
    Functional impairment
    Dissociation/shutdown

Protective Factors

    Supportive caregiver
    Safe adult identified
    Connected to counselling
    School/community support
    Willingness to engage in planning

Reporting and Intervention

    Report submitted to Cybertip.ca:
      - [ ] Yes
      - [ ] No
    Law enforcement involved:
      - [ ] Yes
      - [ ] No
    Child welfare involved:
      - [ ] Yes
      - [ ] No
    Project Arachnid report generated:
      - [ ] Yes
      - [ ] No
    Arthropod monitoring initiated:
      - [ ] Yes
      - [ ] No

Assigned Risk Profile

    - [ ] Risk Profile 1
    - [ ] Risk Profile 2
    - [ ] Risk Profile 3
    - [ ] Risk Profile 4
    - [ ] Risk Profile 5