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Suicide Risk Assessment

SUICIDE PREVENTION AND CRISIS SERVICE
Website: www.suicidepreventionandcrisisservice.org
Phone: 607-272-1616 or 800-273-TALK(8255)

Please print this chart and circle the applicable descriptors.

  High Moderate Low
Time Immediately, in progress, within in few hours Next few days No specific time, sometime in the future
Details Very specific; knows how, when, where Some specifics Vague, no plans
Method Has access to identified means (weapon, pills, alcohol) very specific of how, when, where Uncertain as to access to identified means; some specifics No method planned or very vague, uncertain plan
Chance of Intervention No one nearby, no supervision, isolated Others available, aware and close by Direct eyeball supervision
Previous Attempts/Gestures Multiple attempts of moderate lethality, or one of high lethality - in last 6 months Multiple of low lethality, history of threats - 6 months to one year ago None or one of low lethality - over a year
Interactions Minimal interaction and/or estranged/conflictual interactions with significant others and/or interactions are qualitatively different from baseline One positive connection with significant other and/or interactions are somewhat different from baseline Frequent positive interactions with one or more significant others, no qualitative change in interactions from baseline