Patient name:

Clinical section:

Section/question Risk factor Protective factor

• 1 Current attempt (lethality) L M H N L M H N




• 2 Suicide attempt within last year L M H N L M H N




• 3 Suicidal Ideation L M H N L M H N




• 4 Suicidal intent L M H N L M H N




• 5 Suicidal plan L M H N L M H N




• 6 Past history suicide L M H N L M H N




• 7 Family history suicide L M H N L M H N




• 8 Depression L M H N L M H N




• 9 Anxiety L M H N L M H N

Demographic section:

Section/question Risk factor Protective factor

• 1 Age L M H N L M H N




• 2 Gender L M H N L M H N




• 3 Single, separated, divorced, widow L M H N L M H N




• 4 Race, ethnicity L M H N L M H N

Individual section:

Section/question Risk factor Protective factor

• 1 Religious beliefs L M H N L M H N




• 2 Reason for living L M H N L M H N

Interpersonal relations section:

Section/question Risk factor Protective factor

• 1 Work or school L M H N L M H N




• 2 Family L M H N L M H N




• 3 Spousal or partner L M H N L M H N




• 4 Children L M H N L M H N




• 5 Recent death in family/close friend L M H N L M H N

Situational section:

Section/question Risk factor Protective factor

• 1 Living circumstances L M H N L M H N




• 2 Employment/school status L M H N L M H N




• 3 Availability of firearms or other lethal means L M H N L M H N

Overall assessment:

Rate overall suicide risk as Low (L), Moderate (M), High (H) or range (L-M, M-H) L M H L-M M-H