Client:
Screen completed by:
Date:
sak
Suicide Risk Screener
suicide
assessment
kit
I need to ask you a few questions on how you have been feeling, is that ok?
In the past 4 weeks did you feel so sad that nothing could cheer you up?
1
All of the time
Most of the time
Some of the time
A little of the time
None of the time
In the past 4 weeks, how often did you feel no hope for the future?
2
All of the time
Most of the time
Some of the time
A little of the time
None of the time
In the past 4 weeks, how often did you feel intense shame or guilt?
3
All of the time
Most of the time
Some of the time
A little of the time
None of the time
In the past 4 weeks, how often did you feel worthless?
4
All of the time
Most of the time
Some of the time
A little of the time
None of the time
Have you ever tried to kill yourself?
5
Yes*
No
If Yes:
Once
Twice
3 +
a.
How many times have you tried to kill yourself?
b.
How long ago was the last attempt? __________ (mark below)_ Have things changed since? __________________
In the last 2 months
2-6 months ago
6-12 months ago
1-2 years ago
More than 2 years ago
Yes
Have you gone through any upsetting events recently? (tick all that apply)
6
No
Family breakdown
Conflict relating to sexual
Child custody issues
Other (specify)
identity
Relationship problem
Chronic pain/illness
___________________
Impending legal prosecution
Loss of loved one
Trauma
Have things been so bad lately that you have thought about killing yourself?
7
Yes*
No
If Yes:
a.
How often do you have thoughts of suicide? ______________________________
b.
How long have you been having these thoughts? __________________________
c.
How intense are these thoughts when they are most severe?
Very intense
Intense
Somewhat intense
Not at all intense
d.
How intense have these thoughts been in the last week?
Very intense
Intense
Somewhat intense
Not at all intense
If No:
skip to 10
8
Do you have a current plan for how you would attempt suicide?
Yes*
No
If Yes:
a.
What method would you use? ___________________________________________ (Access to means? Yes
No
)
b.
Where would this occur? _________________________ (Have all necessary preparations been made? Yes
No
)
c.
How likely are you to act on this plan in the near future?
Very likely
Likely
Unlikely
Very unlikely
9
What has stopped you acting on these suicidal thoughts? ___________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
10
Do you have any friends/family members you can confide in if you have a serious problem?
Yes
No
a.
Who is/are this/these person/people?
___________________________________________________________________________
b.
How often are you in contact with this/these person/people? ___________________________
Daily
A few days a week
Weekly
Monthly
Less than once a month
11
What has helped you through difficult times in the past? ____________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
* Indicates high or moderate risk answer