Client Name: _______________________________________
Client Telephone Number: ___________________________
Date of Evaluation:__________________________________

Mark those that are relevant for the client:

___ History of suicide attempts:

___ Medical severity in previous attempts:

___ Age (risk increases with age):

___ Expression of wish to die (verbal or nonverbal):

___ Means, availability, or access to lethal means (guns, pills, knives):

___ Suicidal thoughts, ideation, feelings, plan of action:

___ History of suicide by family members or close friends:

___ Attraction to death:

___ Drug and Alcohol use and abuse:

___ Level of depression (1-5) (e.g. hopelessness, helplessness, sleep/eating patterns with Level 5 being most severe):

___ Recent loss of a loved one (especially loss of a child or elderly spouse):

___ Major psychiatric disorders (other than depression):

___ Major recent physical illness, recent accident/crisis, chronic illness:

___ History of depression or hospitalizations, etc...:

___ Involved with web sites that promote suicide

___ Financial problems:

___ Legal problems:

___ Recent or chronic stressors (e.g. loss, separation, illness, life transition):

___ Marital status (increased risk with single status):

___ Level of social support (increased risk with isolation):

___ Sleep patterns (increased risk with too much or too little sleep):

___ General level of impulse control:

___ Volatility of mood:

___ Physical or sexual abuse in the family:

___ Sexual orientation (increased risk w/ bisexual, sexually active homosexual, celibate):

___ Sense of humor, or ability to reflect cognitively on one's situation:

___ Level of cooperation with treatment (1-5) (e.g. readiness to sign a "No suicide contract", with Level 5 indicating strong commitment to treatment):

___ Recent involvement in risky activities:

___ Excessive dependency on others:

___ Inability to take care of self or others:

___ Additional remarks:

Summary of patient's suicide risk (circle one):
High     Medium     Low     None

Explain:

Action & Care Plan

___ No action required

___ "No Suicide" contract

___ Frequency of contact: sessions, phone, etc...

___ Voluntary hospitalization

___ Involuntary hospitalization

___ Further evaluation

___ Medication, medication evaluation

___ Obtain medical/psych. records, consultations