Suicide Risk Assessment Sample Form

SUICIDE RISK ASSESSMENT FORM
(Adapted from Becks Suicidal Intent Scale)
Objective circumstances related to suicide attempt.
Name: ____________________________________________
Ward: _____________________________________________
Hospital: ___________________________________________
Score:
Clinic: _____________________________________________
1. Isolation: Somebody present
Somebody nearby, or in visual or vocal contact
No-one nearby or in visual or vocal contact
0
1
2
2. Timing: Intervention probable
Intervention unlikely
Intervention highly unlikely
0
1
2
3. Precautions against
discovery/ intervention:
No precautions
Passive precautions, e.g. avoiding others but doing nothing to
prevent their intervention, alone in room w ith unlocked door
Active precautions, e.g. locked door
0
1
2
4. Acting to get help
during/after attempt:
Notified potential helper regarding attempt
Contacted but did not specifically notify potential helper regarding
attempt
Did not contact or notify potential helper
0
1
2
5. Final acts in
anticipation of death (e.g.,
will, gifts, insurance):
None
Thought about or made some arrangements
Made definite plans or completed arrange
0
1
2
6. Active preparation for
attempt:
None
Minimal to moderate
Extensive
0
1
2
7. Suicide note: Absence of note
Note written or torn up, or thought about
Presence of note
0
1
2
8. Overt communicatio n
of intent before attempt:
None
Equivocal communication
Unequivocal communication
0
1
2
9. Alleged purpose or
intent:
To manipulate environment, get attention, revenge
Components of 0 and 2
To escape, solve problems
0
1
2
10. Expectations of
fatality:
Thought that death was unlikely
Thought that death was possible, not probable
Thought that death was probable or certain
0
1
2
11. Conception of
method’s lethality :
Did less to self that thought would be lethal
Was unsure if action would be lethal
Equaled or exceeded what s/he thought would be lethal
0
1
2
12. Seriousness of
attempt:
Did not seriously attempt to end life
Uncertain about seriousness to end life
Seriously attempted to end life
0
1
2
13. Attitude towards
living/dying:
Did not want to die
Components of 0 and 2
Wanted to die
0
1
2
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