Suicide Risk Assessment Sample Form

14. Conception of medical
rescuability:
Thought death would be unlikely with medical attention
Was uncertain whether death could be averted by medical attention
Was certain of death even with medical attention
0
1
2
15. Degree of
premeditation:
None, impulsive
Contemplated for 3 hours or less before attempt
Contemplated for more than 3 hours before attempt
0
1
2
TOTAL SCORE:
RECOMMENDATIONS:
SCORING: RISK: SUGGESTED MANAGEMENT PLAN:
0 -10 LOW May be sent home with advice to see Community Mental Health Team or GP
11 - 20 MEDIUM Assessment by Community Mental Health Team or Psychiatrist advisable.
If treatment refused, Community Mental Hea lth Team follow-up should be
arranged.
Admission may be an option if patient:
Lives alone
Has a history of previous suicide attempt; or
Is clinically depressed
20 - 30 HIGH Immediate assessment by Psychiatrist or Community Mental Health Team.
Psychiatric admission recommended.
Involuntary admission may be required.
ACTION TAKEN: (Tick box applicable)
Admitted: Medical Ward
Psychiatric Ward
Sent home: Alone
With relative/friend
Referred to: Community Mental Health Team
GP
Psychiatrist
Other (specify)
NAME: _________________________________________ Signature: _____________________________
DATE: __________________________________
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Suicide Risk Assessment Sample Form PDF

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