Assessment Context

Reason for risk assessment:

Assessment setting / collateral reviewed:

Assessor / date:

Suicide and Self-Harm Screen

1. Ideation Level

0 — None 1 — Wish Dead 2 — Nonspecific Thoughts 3 — With Method 4 — With Intent 5 — With Plan

1. Actual Attempt

Self-Injurious Behavior with Intent to Die

2. Interrupted Attempt

3. Aborted/Self-Interrupted Attempt

4. Preparatory Acts or Behaviors

5. Non-Suicidal Self-Injury (NSSI)

Most Recent Behavior

yyyy-mm-dd

Lethality (0-10)

Clinician Risk Override

No Override

Mark each item Y, N, or Unknown in the note narrative and expand any positive item in the formulation.

Wandering, absconding, unsafe impulsive behaviour, or language barrier increasing risk

1. How often do you have a drink containing alcohol?

Never (0)Monthly or less (1)2-4 times/month (2)2-3 times/week (3)4+ times/week (4)

2. How many drinks containing alcohol do you have on a typical day when you are drinking?

1-2 (0)3-4 (1)5-6 (2)7-9 (3)10+ (4)

3. How often do you have six or more drinks on one occasion?