Fillable Printable Suicide Risk Assessment Sample Form
Fillable Printable Suicide Risk Assessment Sample Form
Suicide Risk Assessment Sample Form
SUICIDE RISK ASSESSMENT FORM
(Adapted from Becks Suicidal Intent Scale)
Objective circumstances related to suicide attempt.
Name: ____________________________________________
Ward: _____________________________________________
Hospital: ___________________________________________
Score:
Clinic: _____________________________________________
1. Isolation: Somebody present
Somebody nearby, or in visual or vocal contact
No-one nearby or in visual or vocal contact
0
1
2
2. Timing: Intervention probable
Intervention unlikely
Intervention highly unlikely
0
1
2
3. Precautions against
discovery/ intervention:
No precautions
Passive precautions, e.g. avoiding others but doing nothing to
prevent their intervention, alone in room w ith unlocked door
Active precautions, e.g. locked door
0
1
2
4. Acting to get help
during/after attempt:
Notified potential helper regarding attempt
Contacted but did not specifically notify potential helper regarding
attempt
Did not contact or notify potential helper
0
1
2
5. Final acts in
anticipation of death (e.g.,
will, gifts, insurance):
None
Thought about or made some arrangements
Made definite plans or completed arrange
0
1
2
6. Active preparation for
attempt:
None
Minimal to moderate
Extensive
0
1
2
7. Suicide note: Absence of note
Note written or torn up, or thought about
Presence of note
0
1
2
8. Overt communicatio n
of intent before attempt:
None
Equivocal communication
Unequivocal communication
0
1
2
9. Alleged purpose or
intent:
To manipulate environment, get attention, revenge
Components of 0 and 2
To escape, solve problems
0
1
2
10. Expectations of
fatality:
Thought that death was unlikely
Thought that death was possible, not probable
Thought that death was probable or certain
0
1
2
11. Conception of
method’s lethality :
Did less to self that thought would be lethal
Was unsure if action would be lethal
Equaled or exceeded what s/he thought would be lethal
0
1
2
12. Seriousness of
attempt:
Did not seriously attempt to end life
Uncertain about seriousness to end life
Seriously attempted to end life
0
1
2
13. Attitude towards
living/dying:
Did not want to die
Components of 0 and 2
Wanted to die
0
1
2
14. Conception of medical
rescuability:
Thought death would be unlikely with medical attention
Was uncertain whether death could be averted by medical attention
Was certain of death even with medical attention
0
1
2
15. Degree of
premeditation:
None, impulsive
Contemplated for 3 hours or less before attempt
Contemplated for more than 3 hours before attempt
0
1
2
TOTAL SCORE:
RECOMMENDATIONS:
SCORING: RISK: SUGGESTED MANAGEMENT PLAN:
0 -10 LOW May be sent home with advice to see Community Mental Health Team or GP
11 - 20 MEDIUM Assessment by Community Mental Health Team or Psychiatrist advisable.
If treatment refused, Community Mental Hea lth Team follow-up should be
arranged.
Admission may be an option if patient:
• Lives alone
• Has a history of previous suicide attempt; or
• Is clinically depressed
20 - 30 HIGH Immediate assessment by Psychiatrist or Community Mental Health Team.
Psychiatric admission recommended.
Involuntary admission may be required.
ACTION TAKEN: (Tick box applicable)
Admitted: Medical Ward
Psychiatric Ward
Sent home: Alone
With relative/friend
Referred to: Community Mental Health Team
GP
Psychiatrist
Other (specify)
NAME: _________________________________________ Signature: _____________________________
DATE: __________________________________
