Ethics 10
Standard Suicide Risk Assessment
______________________________________________________________________________________
A comprehensive suicidality assessment was conducted due to: (check one about the nature of the referral)
___ Referral source identified suicidal symptoms or risk factors
___ Patient reported suicidal thoughts/feelings on intake paperwork/assessment tools (please attach a copy of the assessment instrument with applicable items circled)
___ Patient reported suicidal thoughts/feelings during the intake interview
___ Recent event already occurred (circle appropriate: suicide attempt, suicide threat)
___ Other:
In the following sections, circle Y for "yes" and N for "no" and provide accompanying details.
________________________________________________________________________
Describe the therapeutic alliance/relationship at the end of the initial session:
Poor-------------Routine-------------Good
If Poor, please indicate problems observed:
________________________________________________________________________
Precipitants to Consider:
Y N Significant loss Describe:
Y N Interpersonal isolation Describe:
Y N Relationship problems Describe:
Y N Health problems Describe:
Y N Legal problems Describe:
Y N Other problems Describe:
Nature of Suicidal Thinking:
Y N Suicide Ideation:
Frequency: Never Rarely Sometimes Frequently Always
Intensity: Brief and fleeting Focused deliberation Intense rumination
Other: _____________________________________
Duration: ____ Seconds ____ Minutes ____Hours
Y N Current Intent
Subjective reports(Provide quote): _______________________________________
Objective signs(behaviors): ____________________________________________________
Y N Suicide plan:
When___________________________________________________________
Where___________________________________________________________
How_______________________________________ Y N Access to means
Y N Suicide Preparation ___________
Y N Suicide Rehearsal_____________________________________________________
Y N Reasons for Dying:____________________________________________________
Y N Reasons for Living: ______________________________________________________
Y N Evidence of emergence of capability to suicide? _______________________________
History of Suicidal Behavior, Self-Harm
Y N History of Suicidality
Ideation_____________________________________________________________
Single Attempt_____________________________________________________________
Multiple Attempts____________________________________________________________
Y N History of Self-Harm (no intent to die)
Type: _______________________________________________________________
Frequency:___________________________________________________________
Duration: ____________________________________________________________
Symptom Severity:
Depression: Rating (1-10)________
Anxiety: Rating (1-10) )________
Anger: Rating (1-10) )________
Agitation: Rating (1-10) )________
Onset of symptom clusters:____________________________________
Duration of symptom clusters:__________________________________
Hopelessness:
Rating (1-10)___________
Onset:________________
Duration:______________
Perceived Burdensomeness:
Rating (1-10)___________
Onset:________________
Duration:______________
Sleep Disturbance:
Rating of severity: (1-10)___________
Initial, middle or terminal insomnia (circle)
Nightmares? Yes or No
Impulsivity/Self-Control:
Y N Impulsivity
Subjective reports: _____
Objective signs: _____________________________________________________________
Y N Substance abuse Describe:
Additional Factors to Consider:
Y N Homicidal ideation Describe:
Recent hospital discharge for suicidality? Y N
How long ago was the discharge? ______________________________________________
Additional risk factors: (check all that apply)
____ Age over 60 ____Male ____Previous Axis I or II psychiatric diagnosis
____ Previous history of suicidal behavior ____History of family suicide
____ History of physical, emotional or sexual abuse ___ Access to firearms
Mental Status:
Alertness: alert…..drowsy…..lethargic……stuporous……other:
Oriented to: person place time reason for evaluation
Mood: euthymic, elevated, dysphoric, agitated, angry,
Affect: flat, blunted, constricted, appropriate, labile
Thought continuity: clear and coherent, goal-directed, tangential, circumstantial, other:
Thought content: WNL, obsessions, delusions, ideas of reference, bizarreness, morbidity, other:
Abstraction: WNL, notably concrete, other:
Speech: WNL, rapid, slow, slurred, impoverished, incoherent, other:
Memory: grossly intact, other:
Reality testing: WNL, other:
Notable behavioral observations:
___________________________________________________________________________
Rating of Acute Risk (circle appropriate category)
None-----Mild-----Moderate-----Severe-----Extreme
___________________________________________________________
Presence/Absence of Chronic Risk (circle appropriate category)
Absent
Present
If present, summarize markers of chronic risk:
_____________________________________________________________________
DSM-5 Diagnosis:
P: At the current time, outpatient care can/cannot provide sufficient safety and stability.
Intervention plan for safety is:
1.
2.
3.
4.
Patient agrees to this plan: Y N
Patient was provided a written crisis response plan: Y N
Patient was provided a commitment to treatment statement: Y N