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:

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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:

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Rating of Acute Risk (circle appropriate category)

None-----Mild-----Moderate-----Severe-----Extreme

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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