SUICIDE RISK ASSESSMENT

Patient: [Name, age]
Date and time: [Date and time of assessment]
Setting: [Primary care, outpatient, emergency department, inpatient, or telehealth; patient's location if remote]
Clinician: [Name, credentials]
Sources: [Patient, family or others, records, other clinicians]

REASON FOR ASSESSMENT
Why now: [Positive screen, disclosure, self-harm or attempt, or concern raised by others]
Screening result: [Tool and result, such as the ASQ, the C-SSRS screener, or PHQ-9 item 9]
Patient's account: [What is happening, in the patient's words]

SUICIDAL IDEATION
Type: [Wish to be dead, or active thoughts of ending one's life]
Onset and frequency: [When the thoughts began and how often they come]
Intensity and duration: [How strong, how long they last, how hard they are to set aside]
Change: [Better, worse, or the same as the patient's usual]
Reasons for dying and for living: [In the patient's words]

PLAN, INTENT, AND PREPARATION
Plan: [Method, place, and timing, and how far worked out]
Intent: [How much the patient means to act, and what they expect would happen]
Preparatory behavior: [Getting means, researching methods, notes, goodbyes, giving things away]
Aborted or interrupted attempts: [What happened, when, and what stopped it]

PAST ATTEMPTS AND SELF-HARM
Past attempts: [Dates, methods, medical severity, intent, how the patient was found]
Most recent attempt: [Circumstances, and how the patient feels about surviving]
Self-harm without intent to die: [Type, frequency, most recent episode]

RISK FACTORS, WARNING SIGNS, AND STRESSORS
Clinical: [Depression, bipolar disorder, psychosis, substance use, recent discharge from hospital]
Medical: [Chronic pain, serious or new illness, disability]
Personal and family: [Family history of suicide, trauma, isolation, impulsivity]
Recent stressors: [Losses, relationship breakdown, legal or money problems, shame]
Warning signs: [Hopelessness, agitation, insomnia, withdrawal, more drinking or drug use, talk of death]

PROTECTIVE FACTORS
Reasons for living and supports: [People, children, pets, faith, future plans]
Coping and engagement: [Skills that have worked, willingness to accept help]

ACCESS TO LETHAL MEANS
Firearms: [Asked directly; number, storage, who holds the keys and ammunition]
Medications: [What is at home and how much, including over-the-counter]
Other means: [Linked to the plan: ligatures, heights, vehicles, chemicals]
What was agreed: [Who will remove, lock up, or reduce each means, and by when]

COLLATERAL
Contacts: [Name and relationship; consent given, or the reason for contact without it]
What they reported: [What confirms or differs from the patient's account]

MENTAL STATUS POINTS THAT BEAR ON RISK
Mood and affect: [Mood in the patient's words; affect observed]
Agitation and anxiety: [Restlessness, panic, sleep]
Thought content: [Hopelessness, guilt, command hallucinations, delusions about death]
Intoxication and cognition: [Whether the patient can be fully assessed now]
Engagement: [Openness, and how consistent the account is]

RISK FORMULATION
Baseline risk: [Long-standing factors that set this patient's risk apart from the general population]
Current risk: [Risk now compared with the patient's own baseline, and why]
Modifiable factors: [What treatment, support, or means safety could change]
Foreseeable changes: [Events that could raise risk soon: discharge, a court date, an anniversary, relapse]
Overall judgment: [Level of concern, the main reasons, and the needs this plan meets]

PLAN
Level of care: [Outpatient, crisis team, intensive outpatient, voluntary or involuntary admission, and why]
Safety plan: [Written with the patient and a copy given, or why not yet]
Lethal means counseling: [What was discussed, with whom, and what was agreed]
Treatment: [Medication changes, therapy, substance use care, referrals]
Who was told: [Who, what was shared, and with what consent or under which exception]
Follow-up: [Date, time, and clinician; who acts if the patient misses it]
Crisis contacts given: [988 by call or text, local crisis line, 911, nearest emergency department]
Consultation: [Supervisor, psychiatrist, or team consulted, and their advice]

Signed: [Clinician name, credentials, date and time]