Suicide and Violence Analysis

Desire

☐Suicidal/violent ideation ☐Psychological pain ☐Hopelessness ☐Helplessness

☐Perceived burden on others ☐Feeling trapped ☐Feeling intolerably alone

Notes:

Capability

☐History of suicide attempts ☐Exposure to suicide or violence in the past ☐Extreme agitation or rage

☐History of/current self-harm or violence toward others ☐Availability of means

☐Substance abuse ☐Currently intoxicated ☐Sleep deprivation ☐Acute symptoms of mental illness

Notes:

Intent

☐Attempt in progress ☐Preparatory behavior ☐Client expressed intent

☐Client has a plan (time and/or method) Always ask the client directly whether they have a plan

Notes:

Buffers/Connectedness

☐Immediate supports ☐Social supports ☐Planning for the future

☐Engagement with crisis worker ☐Core values/beliefs ☐Sense of purpose

☐Client verbalizes reasons for living/no violence ☐Client acknowledges ambivalence

Notes:

Plan of Action

· The Plan of Action should be as detailed as possible and driven by the client.

· The checkboxes below are to guide you. You should detail each step in the numbered section.

☐Self-care (specify) ☐Referrals ☐Medication evaluation ☐Removal of means

☐Involve family or other social supports ☐Verbal no-suicide/violence agreement

☐Hospitalization ☐Follow-up with counselor within 48 hours ☐Other (specify)

1.

2.

3.

Add more steps if needed

Desire

☐Suicidal/violent ideation ☐Psychological pain ☐Hopelessness ☐Helplessness

☐Perceived burden on others ☐Feeling trapped ☐Feeling intolerably alone

Notes:

Capability

☐History of suicide attempts ☐Exposure to suicide or violence in the past ☐Extreme agitation or rage

☐History of/current self-harm or violence toward others ☐Availability of means

☐Substance abuse ☐Currently intoxicated ☐Sleep deprivation ☐Acute symptoms of mental illness

Notes:

Intent

☐Attempt in progress ☐Preparatory behavior ☐Client expressed intent

☐Client has a plan (time and/or method) Always ask the client directly whether they have a plan

Notes:

Buffers/Connectedness

☐Immediate supports ☐Social supports ☐Planning for the future

☐Engagement with crisis worker ☐Core values/beliefs ☐Sense of purpose

☐Client verbalizes reasons for living/no violence ☐Client acknowledges ambivalence

Notes:

Plan of Action

· The Plan of Action should be as detailed as possible and driven by the client.

· The checkboxes below are to guide you. You should detail each step in the numbered section.

☐Self-care (specify) ☐Referrals ☐Medication evaluation ☐Removal of means

☐Involve family or other social supports ☐Verbal no-suicide/violence agreement

☐Hospitalization ☐Follow-up with counselor within 48 hours ☐Other (specify)

1.

2.

3.

Add more steps if needed

Desire

☐Suicidal/violent ideation ☐Psychological pain ☐Hopelessness ☐Helplessness

☐Perceived burden on others ☐Feeling trapped ☐Feeling intolerably alone

Notes:

Capability

☐History of suicide attempts ☐Exposure to suicide or violence in the past ☐Extreme agitation or rage

☐History of/current self-harm or violence toward others ☐Availability of means

☐Substance abuse ☐Currently intoxicated ☐Sleep deprivation ☐Acute symptoms of mental illness

Notes:

Intent

☐Attempt in progress ☐Preparatory behavior ☐Client expressed intent

☐Client has a plan (time and/or method) Always ask the client directly whether they have a plan

Notes:

Buffers/Connectedness

☐Immediate supports ☐Social supports ☐Planning for the future

☐Engagement with crisis worker ☐Core values/beliefs ☐Sense of purpose

☐Client verbalizes reasons for living/no violence ☐Client acknowledges ambivalence

Notes:

Plan of Action

· The Plan of Action should be as detailed as possible and driven by the client.

· The checkboxes below are to guide you. You should detail each step in the numbered section.

☐Self-care (specify) ☐Referrals ☐Medication evaluation ☐Removal of means

☐Involve family or other social supports ☐Verbal no-suicide/violence agreement

☐Hospitalization ☐Follow-up with counselor within 48 hours ☐Other (specify)

1.

2.

3.

Add more steps if needed