IMMINENT SUICIDE RISK & TREATMENT ACTIONS NOTE
Client Name: Date:
Session Start Time: Session End Time:
CURRENT suicidal ideation, impulses, and/or behaviour or urges to self-injure are
(check all that apply):
USUAL “BACKGROUND” suicidality/urges to harm
NEW suicidality/urges to harm
SIGNIFICANTLY INCREASED suicidality/urges to harm
SUICIDE THREAT
Suicide attempt/self-injury SINCE LAST CONTACT
Suicide attempt/self-injury: describe:
CURRENT SUICIDE RISK ASSESSMENT
1) Formal Suicide Risk Assessment was _________(CHECK ONE)
(1) COMPLETED [GO TO QUESTION 3]
(0) NOT COMPLETED, because (CHECK ONE)
(1) CLINICAL REASONS: (CHECK ALL THAT APPLY)
USUAL “BACKGROUND” ideation/urges to harm not ordinarily
associated with increased imminent risk for suicide or medically
serious self-injury
NO OR NEGLIGIBLE SUICIDE INTENT by session end, impulse control
appears acceptable, no new risk factors apparent
Threat or suicidal ideation best viewed as ESCAPE BEHAVIOR and
treatment aims best accomplished by targeting precipitants and
vulnerability factors
Threat or suicide ideation best viewed as OPERANT behaviour; formal
risk assessment may reinforce suicidality
Suicide risk was recently or will soon be assessed by __________Not of
value to have two clinicians treating the same behavior.
Self-injury that occurred CLEARLY NOT IN NEED OF MEDICAL
ATTENTION AT THIS TIME:
Determined by:
(2) REFERRED CLIENT to other responsible clinician for evaluation
(3) OTHER REASON:
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2) IMMINENT suicide risk factors (check ALL):
Not NO YES SUICIDE RISK FACTORS COMMENT
Reported/
Observed
(-3)
HISTORY of suicide attempts/ self-injury
[default from last assessment]
CURRENT suicide intent
Preferred METHOD AVAILABLE or easily
obtained
LETHAL MEANS easily available
PLANNING and/or preparation
PRECAUTIONS against discovery;
deception about timing, place, etc…
ISOLATION, ALONE
PROMPTING EVENTS for previous
parasuicide
SUDDEN LOSS, other negative event
ABRUPT CLINICAL CHANGE, either
negative or positive
INDIFFERENCE/DISSATISFACTION with
therapy
Severe HOPELESSNESS
Severe TURMOIL, ANXIETY, PANIC
attacks, mood CYCLING
Severe GLOBAL INSOMNIA
Severe ANHEDONIA
Inability to CONCENTRATE, INDECISION
PSYCHOSIS, voices telling client to
commit suicide
CHRONIC PHYSICAL pain
CURRENT SUBSTANCE USE, including
ETOH and RX medications (last 3 hours)
OTHER; default = NO:
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IMMINENT suicide protective factors (check all):
Not NO YES PROTECTIVE FACTOR:
Reported/Observed
(-3)
HOPE for the future
SELF-EFFICACY in problem area
ATTACHMENT to life
RESPONSIBILITY to children, family or others who client
would not abandon
ATTACHED to therapy and at least on therapist – WANTS TO
GIVE TREATMENT A CHANCE OF WORKING
THERAPIST attached, will stay in contact
FEAR of act of suicide, death and dying or no acceptable
method available
Belief that suicide is IMMORAL or that it will be punished;
HIGH SPIRITUALITY
Fear of SOCIAL DISAPPROVAL from suicide
COMMITMENT to live and history of taking commitments
very seriously SR51
Other, describe: [default = NO]
3) I believe, based on information currently available to me (Check all that apply)
Client is NOT IMMINENTLY DANGEROUS to self and will be safe from serious
self-injury or suicide until next appointment with me or with primary therapist for
the following reasons: (Check all that apply):
Problems that contribute to suicide risk are being resolved
Suicide ideation reduced by end of contact.
Credible agreement for no self-injury or suicide attempts.
Adequate crisis plan in place.
Suicidality being actively addressed by primary therapist.
Protective factors outweigh risk factors
Describe if not otherwise noted:
____________________________________________________________
OTHER: _____________________________________________________
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Significant UNCERTAINTY EXISTS as to imminent risk, I will get a second opinion
from: (Check All that apply)
SUPERVISOR_____________________________________________________
TEAM MEMBER or
COLLEAGUE_____________________________________________________
MEDICAL EXPERT _________________________________________________
PRIMARY THERAPIST______________________________________________
OTHER__________________________________________________________
Client is at SOME IMMINENT DANGER of ______(Check All that apply):
MEDICALLY SERIOUS self injury
SUICIDE
4) Treatment actions aimed at suicidal/self-injurious behaviours: (Check All that
apply)
Referred:
To primary therapist
To clinician-on-call at
Describe:
For evaluation for involuntary commitment
Describe:
Other:
CRISIS PLAN developed or in place and reviewed
Credible AGREEMENT for no self-injury or suicide attempts
Client agreed TO REMOVE LETHAL means by
Planned a FOLLOW-UP CALL for
Planned client to contact SOCIAL SUPPORT SR60
(who: Will be with boyfriend – he is aware of her behavior)
ALERTED NETWORK to risk:
SR61describe:
Took to ER at
Hospitalization considered; did not recommend because (check all that apply):
Risk is low (default)
Other environmental support available
No bed available
Client refused and involuntary commitment not an option
Client can easily contact me if condition worsens
and/or it would (check all that apply):
Increase long term risk by reinforcing suicidality, uncertain effect on short
term risk
Increase stigma and isolation which are important issues for this client,
Interfere with work or school which are important for this client,
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Violate already agreed to plan,
Cause undue financial burden which is an important issue for this client
Hospitalization arranged at: _______________, to be admitted by:
Client will be re-evaluated for suicide risk no later than (default = next
session):
____1.) 12 hrs, How? __________________________________________
____2.) 24 hrs, How? __________________________________________
____3.) 48 –72 hrs, How? ______________________________________
____4.) Next individual session
____5.) Next group session
____6.) Next pharmacotherapy session
____7.) Other: Describe:
Other: describe:
Next session is scheduled for:
(dd/mm/yyyy)
Signature Supervisor’s Signature
Print Name and Credentials Print Name and Credentials
Date: dd/mm/yyyy Time of Session
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