By Ofer Zur, Ph.D.
The intention of this checklist is to assist therapists in evaluating their clients’ risk of suicide. It is neither scientifically valid nor a reliable, scientifically-proved instrument for the assessment of suicidality. Click here for National Suicide Prevention Lifeline and our Disclaimer.
Client Name: _______________________________________
Client Telephone Number: ___________________________
Date of Evaluation:__________________________________
Mark those that are relevant for the client:
____ History of suicide attempts:
____ Medical severity in previous attempts:
____ Age (risk increases with age):
____ Expression of wish to die (verbal or nonverbal):
____ Means, availability, or access to lethal means (guns, pills, knives):
____ Suicidal thoughts, ideation, feelings, plan of action:
____ History of suicide by family members or close friends:
____ Attraction to death:
____ Drug and Alcohol use and abuse:
____ Level of depression (1-5)
(e.g. hopelessness, helplessness, sleep/eating patterns with Level 5 being most severe):
____ Recent loss of a loved one (especially loss of a child or elderly spouse):
____ Major psychiatric disorders (other than depression):
____ Major recent physical illness, recent accident/crisis, chronic illness:
____ History of depression or hospitalizations, etc…:
____ Involved with web sites that promote suicide
____ Financial problems:
____ Legal problems:
____ Recent or chronic stressors (e.g. loss, separation, illness, life transition):
____ Marital status (increased risk with single status):
____ Level of social support (increased risk with isolation):
____ Sleep patterns (increased risk with too much or too little sleep):
____ General level of impulse control:
____ Volatility of mood:
____ Physical or sexual abuse in the family:
____ Sexual orientation (increased risk w/ bisexual, sexually active homosexual, celibate):
____ Sense of humor, or ability to reflect cognitively on one’s situation:
____ Level of cooperation with treatment (1-5)
(e.g. readiness to sign a “No suicide contract”, with Level 5 indicating strong commitment to treatment):
____ Recent involvement in risky activities:
____ Excessive dependency on others:
____ Inability to take care of self or others:
____ Additional remarks:
Summary of patient’s suicide risk (circle one):
High Medium Low None
Explain:
Eight critical risk factors for suicide in patients with major depression
Researchers identify eight critical risk factors for suicide in patients with major depression, in a study published in Professional Psychology: Research and Practice, 30, No. 6, p. 576-580. In a survey presented participants with 48 risk factors derived from previous studies involving suicide and depression. Practitioners in this study considered the following eight factors most important:
- The medical seriousness of previous attempts.
- History of suicide attempts.
- Acute suicidal ideation.
- Severe hopelessness.
- Attraction to death.
- Family history of suicide.
- Acute overuse of alcohol.
- Loss/separations.
Action & Care Plan
___ No action required
___ “No Suicide” contract [Note: This intervention is controversial, see article The Case Against No-Suicide Contracts: The Commitment to Treatment Statement as a Practice Alternative.]
___ Frequency of contact: sessions, phone, etc…
___ Voluntary hospitalization
___ Involuntary hospitalization
___ Further evaluation
___ Medication, medication evaluation
___ Obtain medical/psych. records, consultations
___ Others:
Emergency Resource & Our Disclaimer:
This page provides only general information and general education regarding a variety of teen issues. It is neither a substitute to medical or mental health treatment nor is it a substitute for calling 911 or emergency services. If you are feeling suicidal, thinking about hurting yourself, or are concerned that someone you know may be in danger of hurting herself or himself, call 911 ASAP or the National Suicide Prevention Lifeline at 1-800-273-TALK (1-800-273-8255). This phone service is available 24 hours a day, 7 days a week and is staffed by certified crisis response professionals who may be able to direct you to a crisis center in your area anytime 24/7.