SUICIDE RISK SCREENING PROCESS
Suicide Risk Assessment Date: Time:
Checklist patient:
Patient name: Contact Number:
Risk Assessors (individuals conducting risk assessment):
Referral Source (who referred the individual for risk assessment):
Reason for Assessment: (Describe the cause for concern to include specific behaviors/comments heard or
reported)
Ideation Definition and Prompts Past
Month
Ask questions that are bolded and underlined. Yes No
Ask Question 1 and 2
1. Wish to be Dead:
Person endorses thoughts about a wish to be dead or not alive anymore, or wish to fall
asleep and
2. Suicidal not wake up.
Thoughts:
Have you wishedHave
you were dead orhad
you actually wished
any you couldof
thoughts gokilling
to sleep and not wake up?
yourself?
If YES to 2 ask questions 3, 4, 5, and 6. If NO to 2, go directly to question 6.
3. Suicidal Thoughts with Method (without Specific Plan or Intent to Act):
Have you been thinking about how you might kill yourself?
4. Suicidal Intent (without Specific Plan): Active suicidal thoughts of killing oneself and
patient reports having some intent to act on such thoughts, as opposed to “I have the
thoughts but I definitely will not do anything about them.”
Have you had these thoughts and had some intention of acting on them?
5. Suicide Intent with Specific Plan:
Have you started to work out or worked out the details of how to kill yourself? Do you
intend to carry out this plan?
6. Suicide Behavior Question:
Have you ever done anything, started to do anything, or prepared to do anything to end
your life?
If YES, ask: How long ago did you do any of these?
Comments:
Name:
Signature: Date:
Additional Assessment Questions YES N ?
Categories
In the past year, felt so sad he/she stopped doing
7. regular activities?
Specify:
8. Demonstrated abrupt changes in behaviors? (e.g.
Changes in eating, sleeping, decline in school performance, quit
Mood/Behavior club/sports activities, gave away personal possessions)
9. Demonstrated recent, dramatic changes in mood?
(e.g., change from depression to contentment,
happiness to depression, etc.)
10. Experiencing emotional pain that feel unbearable?
(e.g., desperate for relief from pain, willing to do
anything to stop the pain, etc.)
11. Had a personal connection to, or identified with,
someone who committed suicide?
Who:
12. Had a recent death of a loved one or a significant loss?
(i.e. breakup of a romantic relationship)
13. Experienced a new trauma/stressor?
Stressors Specify:
What:
14. Experienced a chronic/ongoing stressor? (feelings of
loneliness, life stress )
Specify:
15. Experienced a significant health concern? (self or
other)
Specify:
16. Experienced abuse or victimization?
Specify:
17. Has a history of mental illness? (i.e., depression,
conduct, or anxiety)
Mental Illness Specify:
18. Currently in counseling?
With whom:
Substance Use 19. Has a history of substance abuse?
Specify:
20. Has a support system of family, friends, or pets?
Specify:
Protective 21. Has a sense of purpose in his/her life? (Commitments,
Factors plans, etc.)
Specify:
22. Readily names plans for the future/indicates a reason
to live?
Specify:
23. Who would be hurt if the plan was carried out?
(Family, friends, pet, etc.)
Specify:
24. Who would the individual want to stop him/her if
he/she had a plan?
Specify:
25. What happens to people who die? (religion/spiritual
beliefs)
Response:
26. What happens to people who die by suicide?
(religion/spiritual beliefs)
Response
27. Engages in risky behavior? Specify:
28. Impulsive acting-out? (Quickly escalates conflict,
Personal flees/runs away, etc.)
Factors Specify:
29. Affect: ☐ Calm ☐ Elated ☐ Labile ☐ Irritable ☐
Enraged ☐ Depressed/Despondent
Behavior: ☐ Cooperative ☐ Withdrawn ☐ Avoidant
☐ Defensive ☐ Hostile ☐ Varied
LOW RISK
The individual does not pose imminent danger to self; insufficient evidence for suicide potential. Low
risk indicators may include: thoughts of suicide only in the past; history of depression; no previous
attempts; no plan; no access to weapons or means; no recent losses; support system in place; no
alcohol/substance abuse; positive coping skills. A Coping Plan should be completed with the individual.
MODERATE RISK
The individual presents with a questionable or non-viable plan of self-harm (i.e., lacks clear or viable
intent, ideation, and/or plan) but is deemed to be at elevated risk of harming him/herself due to current
stressors, personal and/or environmental variables, and/or lack of protective factors.
HIGH RISK
The individual poses imminent danger to self with a viable plan to do harm. High risk indicators may
include: current thoughts of suicide; current sense of hopelessness; previous attempts; access to
weapons or means; weak support system; alcohol/substance abuse; mental health history; precipitating
events, such as loss of loved one, traumatic event, or feelings of victimization. The individual must be
sent for an immediate mental health assessment by a medical professional or hospital.
Coping Plan
Step 1: Warning signs/Triggers
Step 2: “By myself” Coping Tools: Things I can do to take my mind off my problems:
Step 3: People and places that I can go to who/which will distract me, to make me feel better:
At work:
Who:
Where:
At Home:
Who:
Where:
Step 4: People who care about me and who I can ask for help
Name Relationship Contact Information
Step 5: Reasons to Live
Step 6: Safety resources if you need help right away-
1. SADAG: 011 234 4837/WHATSAPP LINE (076 882 2775) OR SMS 31393
2. SUICIDE CRISIS HELPLINE: (0800 567 567)
[Link] MENTAL HEALTH HELPLINE (0800 456 789) WHATSAPP LINE ( 076 882 2775)
Patient Signature: Date:
Staff Signature: Date: