SUICIDE RISK ASSESSMENT CHECKLIST
INFORMATION
Date(Y/M/D):
Name:
Address:
Student #:
Birthdate (Y/M/D):
City:
Postal Code:
Telephone:
Cell:
DEGREE OF RISK
□ LOW
No plan - non-emergency
□ MEDIUM
Has a plan - no imminent danger
□ HIGH
Emergency – has a plan, likely to act
SUICIDAL THOUGHTS
Frequency:
Intensity right now:
How bad does it get?
Critical event(s)/trigger(s):
□ Hourly
□ Daily
□ Weekly
□ Monthly
Low 1 2 3 4 5 6 7 8 9 10 High
Manageable 1 2 3 4 5 6 7 8 9 10 Unbearable
□ Yes □ No
If yes,
Prior suicidal thoughts
□ Yes
□ No
If yes, describe
Prior suicide attempt
□ Yes
□ No
If yes, describe
Current plan
□ Yes
□ No
Timeline and means:
Access to means / method
□ Yes
□ No
RISK FACTORS
Client lives alone
Client reports indifference / apathy
Substance abuse disclosed
History of suicide by friend / family member
Expresses unbearable hopelessness
Recent loss of loved one
Impulsivity
Recent stressful events
Nothing seems good enough any more
Current crisis
Recent relationship breakup
Being bullied
Concluding personal affairs (banking/will)
Agitation is evident
□ Yes □ No
□ Yes □ No
□ Yes □ No
□ Yes □ No
□ Yes □ No
□ Yes □ No
□ Yes □ No
□ Yes □ No
□ Yes □ No
□ Yes □ No
□ Yes □ No
□ Yes □ No
□ Yes □ No
□ Yes □ No
Client reports anger toward others
Client has been giving away possessions
Depressive symptoms evident
Direct statement of intent to suicide
Indirect statements of intent to suicide
Health issues
Rigid thinking (inflexible / lack of openness)
Lack of sense of belongingness
Loss of familiar environment / connections
Family problems (particularly if longstanding)
LGBTQ issues
Detaching from social / personal relationships
Confused mental state is evident
Mental health diagnosis: __________________
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□ Yes □ No
□ Yes □ No
□ Yes □ No
□ Yes □ No
□ Yes □ No
□ Yes □ No
□ Yes □ No
□ Yes □ No
□ Yes □ No
□ Yes □ No
□ Yes □ No
□ Yes □ No
□ Yes □ No
□ Yes □ No
CONTRAINDICATIONS
A viable support system is available
Moral / religious restraints against suicide
History of physical / emotional wellbeing
Upon recovery, satisfying life situation exists
□ Yes □ No
□ Yes □ No
□ Yes □ No
□ Yes □ No
Maintaining contact with significant others
Signs of affective openness and rapport
Positive attitude toward personal responsibility
Is receiving mental health care
□ Yes □ No
□ Yes □ No
□ Yes □ No
□ Yes □ No
Available resources:
ACTION TAKEN
Advised of emergency department
Provided crisis line / Good Talk contact information
Accompanied to emergency department
Contacted CMHA Mobile Crisis Team
Contacted police / 911
Contacted family doctor
Contacted family / friends / partner
Consulted with ____________________________________________ Position ________________________
Counselling appointment scheduled
Other (describe):
Consent form(s) attached □ Family □ Friend □ Physician □ Therapist □ Other: ______________________
□ Consent refused
FOLLOW UP PLAN
Therapist:
Date (Y/M/D):
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□ Yes □ No
□ Yes □ No
□ Yes □ No
□ Yes □ No
□ Yes □ No
□ Yes □ No
□ Yes □ No
□ Yes □ No
□ Yes □ No
□ Yes □ No
□ Yes □ No