"Suicide Risk Assessment Template"

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Appendix B: Suicide Assessment
Crisis Assessment Form – Guidelines*
risk assessment
Part A: Danger to Self
Suicidal Ideation:
Yes
No
• Are you currently having any thoughts of hurting yourself (self-harm) or
suicidal thoughts?
• If yes, tell me more about what the thoughts are (find out specifics).
• Are the thoughts increasing in frequency and intensity?
• Are you spending a lot of time contemplating suicide or hurting yourself,
or are they fleeting thoughts? (during the last
hours)
• How are you responding to the thoughts? (dwelling vs. distracting self)
Active suicidal thought with intensity, increasing frequency, and occupying a lot
of time all increase risk.
Suicidal Plan:
Yes
No
• Are you spending a lot of time planning how you would hurt or kill
yourself?
• Do you have a specific plan?
• Find out as many details as possible about the plan (when, what, where,
how).
• Do you have a specific date of when you would hurt or kill yourself?
• Is there anything that would hold you back? (e.g., family, friends, religious
convictions, pet)
A well-thought-out plan increases risk.
Access to Plan:
Yes
No
• Do you have access to your plan? (e.g., Do you have a gun or are you able
to get a gun?)
• If plan involves an overdose, ask what pills they plan to take, where the
*Developed by Sandra Cushing,
, and
pills are now, and have they been stockpiling pills?
Susan Boyd,
, Alcohol, Drug and Gambling
Services, Social and Public Health Services
• Assess location of means (e.g., Where is the gun/rope/pills, etc.?)
Division, City of Hamilton and Regional
Municipality of Hamilton-Wentworth.
The more accessible the plan, the higher the risk.
Reprinted by permission of the authors.
appendix b
17
Appendix B: Suicide Assessment
Crisis Assessment Form – Guidelines*
risk assessment
Part A: Danger to Self
Suicidal Ideation:
Yes
No
• Are you currently having any thoughts of hurting yourself (self-harm) or
suicidal thoughts?
• If yes, tell me more about what the thoughts are (find out specifics).
• Are the thoughts increasing in frequency and intensity?
• Are you spending a lot of time contemplating suicide or hurting yourself,
or are they fleeting thoughts? (during the last
hours)
• How are you responding to the thoughts? (dwelling vs. distracting self)
Active suicidal thought with intensity, increasing frequency, and occupying a lot
of time all increase risk.
Suicidal Plan:
Yes
No
• Are you spending a lot of time planning how you would hurt or kill
yourself?
• Do you have a specific plan?
• Find out as many details as possible about the plan (when, what, where,
how).
• Do you have a specific date of when you would hurt or kill yourself?
• Is there anything that would hold you back? (e.g., family, friends, religious
convictions, pet)
A well-thought-out plan increases risk.
Access to Plan:
Yes
No
• Do you have access to your plan? (e.g., Do you have a gun or are you able
to get a gun?)
• If plan involves an overdose, ask what pills they plan to take, where the
*Developed by Sandra Cushing,
, and
pills are now, and have they been stockpiling pills?
Susan Boyd,
, Alcohol, Drug and Gambling
Services, Social and Public Health Services
• Assess location of means (e.g., Where is the gun/rope/pills, etc.?)
Division, City of Hamilton and Regional
Municipality of Hamilton-Wentworth.
The more accessible the plan, the higher the risk.
Reprinted by permission of the authors.
appendix b
17
Preparations Made:
Yes
No
• Find out details of any previous attempts made (what did they do?)
• How many past attempts? What happened? Who found you? Did you
require medical attention?
• Did you tell anyone about the suicide attempt?
• Did you try to hide the attempt from others?
• Was your aim to kill yourself or was it accidental?
• Also ask if the person has ever come close to taking any action or risky
behaviour that has resulted in a threat to his or her life (e.g., unintentional
and/or past risky actions/behaviours).
• Assess the lethality of previous attempts and/or past risky actions/behav-
iours.
• How is the current suicide/self-harm plan similar or different from past
attempts?
Serious lethal attempts and/or attempts made in isolation increase risk level.
Command Hallucinations:
Yes
No
• Are you hearing any voices or seeing any visions telling you to harm or kill
yourself?
• Are you receiving any messages (e.g., from internal or external sources —
radio or
)?
• If yes, what is the voice saying? What is the vision? Whose voice is it?
• How often is the voice or vision occurring?
• Are others involved?
• How is the voice or vision making you feel? (scared? Is it a derogatory
voice?)
If the person is experiencing command hallucinations, immediate hospital or
medical attention should be sought to ensure his or her safety. The person may
be admittable to hospital on an involuntary basis, if he or she is unable to go on
his or her own.
Family/Network History:
Yes
No
• Have any of your family members or close friends or acquaintances com-
pleted suicide or made serious attempts?
• If so, when?
18
helping the problem gambler
• How did they complete suicide?
Risk increases if family/network history of completed suicide exists and risk fur-
ther increases the more recent the family/network completed suicide.
Part B: Danger to Others
Homicidal Thoughts:
Yes
No
• Are you currently having any thoughts of hurting or killing anyone?
• What thoughts are you having? Tell me more (get specific details).
• Who are the thoughts about?
• How far are you away from that (those) persons(s)? How long would it
take you to find them?
• Is there anyone there with you right now? (Assess the safety of that person)
• How much time are you spending thinking about hurting or killing that
(those) person(s), or someone? Are the thoughts fleeting?
• Have you pictured yourself following through with your plan?
• Is the intensity of the thoughts increasing?
Current Violent Thought:
Yes
No
Plan
• Find out as many details as possible.
• Who does it involve?
• How soon do they plan to carry it out?
• What means (weapons, etc.) does it entail? Are the means to carry out the
plan in place?
• When do they intend to act on their thoughts/plan?
Also assess general thoughts of violence or anger. (e.g., Do such thoughts relate
to past abuse/trauma? How do they express anger and violence?)
Access to Plan:
Yes
No
. Is (are) the person(s) you are wishing to harm/kill within access (versus
feeling vengeful toward someone you have lost track of and are unable to
locate).
. Do you have weapons/means in place to carry out the plan? (How easily
can client access the means/weapons needed?)
appendix b
19
. Have you started to follow that person (e.g., stalking)? (Does client know
the person’s routine?)
. If you are following the person, are you carrying weapons with you?
History of Violence:
Yes
No
. Have you had any past history of violence toward others? If yes, find out
details of violent acts — what, when, who, consequences, remorse.
. Have you ever been a victim of violence/abuse?
. Have you ever been charged and/or convicted of violence (assault) in the
past? (When, what was the nature of the offence, etc.)
Fears and Consequences:
Yes
No
. Are you concerned about the potential consequences if you act on your
plan to harm/kill someone else? (e.g., legal, incarceration, impact on other
person and family, remorse)
Command Hallucinations:
Yes
No
• Are you hearing any voices (internal or external) or seeing any visions
telling you to hurt or kill someone else?
• If yes, where are the voices/visions coming from?
• What are the voices/visions telling you?
• Do you recognize the voice or the person(s) in the vision?
• How are you coping with hearing the voices? Seeing the vision?
• How long have the voices/visions been occurring? Are they intensifying
(occurring more frequently, for longer periods of time)?
If command hallucinations are occurring, risk of harm to others is very high.
Immediate medical attention/psychiatric assessment should be sought. If person
is unwilling to do so, an involuntary hospital admission may be needed.
Overall Evaluation of Risk for Danger to Others:
None
Low
Moderate
High
• Risk is high if the individual has a clear plan, means and access to the per-
son(s) he or she wishes to harm or kill.
• Command hallucinations also present high risk. Hallucinations could
lead the individual to act impulsively, even if a clear plan and access are
not in place.
20
helping the problem gambler
• A violent history, lack of remorse, no fear of consequences all further risk.
None to Low risk when thoughts are more based in anger with no plan of action
and no access/means available to act on thoughts.
Client Presentation:
Angry
Agitated
Anxious
Paranoid/delusional
Hallucinating
Disoriented
Coherent
Indifferent
Sadness
Incoherent
Labile
Alert
Weight change
Sleep change
Substance abuse
Hopeless/helpless
Self-harm
Appetite disturbance
*Labile — rapid fluctuation in mood/presentation (i.e., crying to angry)
Specifics:
Risk Assessment:
Danger to self
Yes
No
Suicidal ideation
Yes
No
Suicide plan
Yes
No
Access to plan
Yes
No
Preparations made
Yes
No
Previous attempts
Yes
No
Command hallucinations
Yes
No
Family/network history
Yes
No
appendix b
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