Suicide Risk Assessment

Consumer:__________________________ CID#___________________
Strengths
Needs
Abilities
Preference
s
DIRECTIONS: Assess the risk of the client in each of the following categories and add the points. If the
question does not apply, use zero.
S QUESTION LOW MODERATE HIGH
C 1 point each 2 points each 3 points each
O
R
E
Does the client have signs Mild, able to carry out Low energy, Severe, hopeless, helpless,
of depression? (no daily functions apathetic, feelings of worthlessness,
enjoyment of life, withdrawn, not mood swings, unable to
hopelessness, difficulty coping well, some function
sleeping and/or eating,) difficulty with daily
function
Has the client ever No attempts Previous thoughts, Has attempted;
attempted suicide? no attempt; hospitalized or E.R. care
thoughts of death
Has a family member ever Rumored, but never Distant family Immediate family member
attempted suicide? disclosed clearly member or friend or loved one
Does client have a suicide Vague, fleeting Frequent thoughts; Frequent or constant
plan? thoughts, but no plan occasional ideas thoughts with a plan;
about a plan giving away possessions;
expresses will to die and
has written a suicide note
Does client have access No access Has decided on a Immediate accessibility
to whatever is necessary method but does not
to carry out his/her plan? have access
Is client isolated socially Begun to alienate Alienated many Socially isolated; alienated
without friends? family and friends family and friends all
Level of drug/alcohol use? Infrequently Frequently to excess Continual abuse; presently
intoxicated; withdrawal
Does the client have a Mild Moderate Severe
chronic physical illness
and/or chronic pain
Does the client have a None Within last six Recent, within last month
history of self destructive months
behaviors (self mutilation,
accident prone,
recklessness)?
Is client presently No Somewhat Severe; disoriented;
psychotic or paranoid? disorganized; mild extreme paranoia;
paranoia psychotic thoughts and
behaviors
Has client sustained a Loss, which is not Recent death of Death of a spouse, parent,
recent loss? (job, friend, significant to client friend or pet, child, significant other; loss
loved one, home, status) yet is still a loss, job demotion, money of job; financial disaster;

Date: _________ Clinician Signature:_______________________________ Clinician

Name:_______________________________
 Suicide Risk Assessment
S QUESTION LOW MODERATE HIGH
C 1 point each 2 points each 3 points each
O
R
E
within three months? change, minor job crunch, serious terminal illness
problems, poor health illness
Is the client willing to Willing Willing with some Not willing
making a no harm reservations
contract?
What is the client’s level None Some Severe
of impulsivity?
What is the client’s level None Some Severe
of hostility?
Is client compliant with Takes as prescribed Takes infrequently Has discontinued meds
medication?
______ TOTAL POINTS

CIRCLE RISK CATEGORY LOW = 16 MODERATE = 17 - 32 HIGH = 33

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Date: _________ Clinician Signature:_______________________________ Clinician

Name:_______________________________