Cleveland State University
Suicidal/Homicidal Desire
To what extent has the individual…
been having thoughts of suicide?
expressed thoughts of being intolerably alone
expressed feelings of hopelessness
expressed feelings of helplessness?
expressed feelings of being a burden on others?
expressed feelings of being trapped?
been experiencing psychological pain?
tried coping skills without relief?
None
0
0
0
0
0
0
0
0
Mild Moderate Severe Unknown
1
2
3
0
1
2
3
0
1
2
3
0
1
2
3
0
1
2
3
0
1
2
3
0
1
2
3
0
1
2
3
0
Suicidal/Homicidal desire subscale (0-24):_____
Suicidal/Homicidal Capability
Yes
No
Unknown
Has the person ever attempted suicide/homicide?
3
0
0
Has the person been exposed to death by suicide/homicide?
3
0
0
Available means to hurt him/herself or others?
3
0
0
Does the person have a history of violence toward others?
3
0
0
Is the person currently intoxicated?
3
0
0
Is the person currently taking substances?
3
0
0
Does the person have a history of AoD abuse?
3
0
0
Is the person experiencing acute MH symptoms?
3
0
0
Does the person seem to be out of touch with reality?
3
0
0
Is the person exhibiting increased agitation/rage?
3
0
0
Has the person been experiencing recent dramatic mood swings? 3
0
0
Has the person experienced increase anxiety or panic?
3
0
0
Has the person experienced problems sleeping recently?
3
0
0
Suicidal/Homicidally capability subscale score (0-39): _____
Suicidal/Homicidal Intent
Yes
No
Unknown
Is the person currently attempting suicide/homicide?
20
0
0
Actively planning a suicide/threats toward others attempt?
10
0
0
Involvement in preparing for their or another’s death?
5
0
0
Is the person currently expressing an intent to die/to hurt someone?
5
0
0
Suicidal/Homicidal intent subscale score (0-40): _____
Protective Factors
To what extent has the individual…
None Mild Moderate Strong Unknown
Have access to immediate supports?
0
1
3
5
0
Belong to a social support system?
0
1
3
5
0
Have a plan for the future?
0
1
3
5
0
Express ambivalence for dying/hurting another?
0
1
3
5
0
Express a sense of purpose?
0
1
3
5
0
Live by core values or a belief system?
0
1
3
5
0
Engage with the the therapist in session?
0
1
3
5
0
Verbalize what is keeping the connected?
0
1
3
5
0
Identify triggers that are different today?
0
1
3
5
0
Protective factors subscale score (0-45): _____
Suicide/Homicide Risk Score Below
Capability
Low suicidal risk=0-29
Capa
bility
+
Intent
+
ç
Desire
Protective Factors
-
hg
==
Moderate suicidal risk = 30-59
=jj
ç
Score
=
hg
==
High suicidal risk= 60 & up
=jj
Signature and credentials of provider_____________________________________________Date:____________