Suicide Assessment Five Step Evaluation and Triage (SAFE-T)
Patient Name: _____________________________________ DOB : ___/___/___ Today’s Date: ___/___/___
1. Risk Factors Note those that can be modified to reduce risk
Suicidal behavior none past attempts aborted attempts rehearsals self-harm
Current/past psychiatric diagnoses and treatment
Key symptoms
anhedonia panic attacks
impulsivity global insomnia
hopelessness command hallucinations
anxiety
Family history of suicidal behavior none History includes:
Precipitants/stressors/interpersonal
academic major loss
family major trauma
relationships/ social financial
reputational legal
vocational
Change in none discharge from psych facility non-compliance with RX recent RX change
Treatment
Risk Behaviors none substance abuse alcohol self-harm inappropriate sexual behavior
Access to weapons, sharps, meds (RX/OTC)
Copyright© 2015 by Girls to Women Health and Wellness. All Rights Reserved. Based on Suicide Assessment Five-Step Evaluation and Triage (SAFE-T). Go to SPRC.org for more information.
2. Protective Factors Note those that can be enhanced
Internal ability to cope with stress religious beliefs frustration tolerance absence of psychosis
External responsibility to family or pets positive therapeutic relationships social supports
3. Suicide Inquiry Suicidal thoughts, plans, behavior and intent
Last 48 Hours Past Month Worst Ever
Frequency
Ideation
Intensity
Duration
Current Plan none timing location lethality availability preparatory acts
Behaviors none past attempts aborted attempts rehearsals self-harm
Current Intent none expects to carry out plan believes plan is lethal believes plan is self-injurious
Reasons to die
Reasons for live
Copyright© 2015 by Girls to Women Health and Wellness. All Rights Reserved. Based on Suicide Assessment Five-Step Evaluation and Triage (SAFE-T). Go to SPRC.org for more information.
4. Risk Level Determine risk. Choose appropriate intervention to address and reduce risk
Risk/Protective Factors Suicidality Possible Interventions
High Psychiatric disorders with severe Potentially lethal suicide Admission generally indicated unless a
symptoms, or acute precipitating attempt or persistent significant change reduces risk.
event; protective factors not ideation with strong intent Suicide precautions
relevant or suicide rehearsal
Moderate Multiple risk factors, few Suicidal ideation with plan, Admission may be necessary depending on
protective factors but no intent or behavior risk factors. Develop crisis plan.
Give emergency/crisis numbers
Low Modifiable risk factors, strong Thoughts of death, no Outpatient referral, symptom reduction.
protective factors plan, intent or behavior Give emergency/crisis numbers
5. Document Treatment Plan Assessment of risk, rationale, intervention and follow-up (ECW browse text setup)
Risk/Protective Factors High Moderate Low
Suicidality High Moderate Low
Intervention Level High Moderate Low
Medication
Suicide Precautions Advised
Daily close monitoring and supervision, ongoing consistent contact with safe individuals, restrict access to weapons (including firearms, knives, ropes,
dangerous machinery, etc.) and medications (Rx and OTC). Counseled on supportive strategies to ensure safety and minimize conflict while arranging
for further assessment or monitoring for response to treatment.
Suicide Prevention Plan Provided
Crisis Plan Developed with Patient
Follow-up (who and when)
GTW
Psychiatrist
Therapist
Hospital
Treatment Center
Copyright© 2015 by Girls to Women Health and Wellness. All Rights Reserved. Based on Suicide Assessment Five-Step Evaluation and Triage (SAFE-T). Go to SPRC.org for more information.
