Pediatric Suicide/Self-Harm Risk Assessment Note

Date/Time of Assessment: [Date and time of assessment]

Patient Name: [Patient full name]

DOB/Age: [Date of birth and age]

MRN: [Medical record number]

Clinician Name/Role: [Clinician name and role/title]

Setting: [ED / inpatient / outpatient clinic]

Reason for Assessment: [Trigger for assessment, e.g., positive screen, self-harm event, disclosure, collateral report]

Immediate Safety Status

[Current safety measures in place, including observation level, removal of dangerous items from environment and patient, and whether patient may leave unaccompanied; for outpatient settings include who is physically present and transportation plan if escalation needed] (If any element is pending or unknown, state what is pending rather than leaving blank.)

Sources of Information

• Primary historian(s): [Names and roles of those interviewed, e.g., patient, parent/guardian, others]
• Patient interviewed alone: [yes / no] (If no, provide brief rationale.)
• Caregiver interviewed separately: [yes / no]
• Collateral sources: [Relationship, date/time, method, and key information obtained] (Omit if none.)
• Reliability limitations: [Factors affecting reliability such as intoxication, developmental level, guardedness, language barriers, or conflicting accounts] (Omit if none.)

(Throughout the note, clearly distinguish patient report vs caregiver/collateral report vs chart review.)

Screening Tools

(Include this section only if validated screening tools were administered; omit entirely if none were used.)

• Tool: [Name and version, e.g., ASQ, C-SSRS, PHQ-A item 9]
• Administration: [Who administered, date/time, whether caregiver was present]
• Results: [Overall result and item-level responses when clinically relevant]
• Action taken: [Immediate steps informed by results]

(If tool was indicated but not performed, document reason and alternative clinical assessment used.)

Suicide and Self-Harm Assessment

Current Suicidal Ideation

• [Presence or absence of passive thoughts of death vs active suicidal ideation]
• Timeframes: [Right now during this session; past 48 hours; past month]
• [Frequency, intensity, duration, and triggers]
• [Verbatim statements of intent or explicit threats in quotation marks]

(If unable to assess, state reason and compensatory action taken.)

Plan

• [Presence or absence of a plan] (If none, note whether a hypothetical method was disclosed.)
• [Method considered, perceived lethality and feasibility]
• [Timing or location if specified]
• [Preparatory actions, e.g., collecting means, searching methods online, writing notes, giving away possessions]

Intent

• [Stated intent to die vs ambivalence]
• [Expectation of carrying out the plan and perceived lethality]
• [Reasons to die vs reasons to live]
• [Current impulse control and stated ability/willingness to use safety strategies]

Suicide Attempts and Self-Harm Behaviors

• Suicide attempts: [Method, approximate date, medical severity, stated intent at the time, treatment received] (Omit if none.)
• Aborted or interrupted attempts: [What stopped the act] (Omit if none.)
• Non-suicidal self-injury: [Method, frequency, function such as emotion regulation, medical care required] (Omit if none. Avoid ambiguous terms; use observable descriptions.)

Other Safety-Relevant Findings

(Include this subsection only if any of the following are present; omit entirely if none.)

• [Homicidal ideation or violent ideation]
• [Psychotic symptoms, including command hallucinations if present]
• [Substance use proximate to ideation or behavior]
• [Severe sleep deprivation, agitation, or affective instability]
• [Recent significant losses or conflicts]
• [Suicide exposure or contagion factors]

Access to Means

(Assess each relevant environment. Indicate yes, no, or unknown with brief details. If unknown, state why and how this affects disposition.)

• Primary home:
  • Firearms: [yes / no / unknown] [Type, storage, ammunition location, patient knowledge of access]
  • Medications: [yes / no / unknown] [Prescription and OTC, quantities, who controls access, lockbox use]
  • Sharp objects: [yes / no / unknown]
  • Ligatures: [yes / no / unknown]
  • Other hazards relevant to stated plan: [Details]
• Other caregiver homes: [As above, if applicable]
• Vehicle: [As above, if relevant]

Means-Safety Counseling

• Counseling provided: [Summary of education and rationale discussed with patient and caregiver]
• Agreed-upon actions: [Who will do what, by when, and how it will be verified]
• Firearms: [Removal from home or locked storage; who controls keys or combination]
• Medications: [Lockbox plan and supervision of administration if indicated]
• Other means restriction: [Sharps, ligatures, environmental modifications]
• Caregiver understanding: [Document teach-back and verbalized agreement]

Risk and Protective Factors

• Static risk factors: [Prior suicide attempts, family history of suicide, prior psychiatric hospitalization, chronic conditions]
• Dynamic risk factors: [Current stressors, acute intoxication or withdrawal, recent loss, access to means, sleep deprivation, acute psychiatric symptoms]
• Protective factors: [Connected relationships, engaged caregiver, future orientation, willingness to seek help, reasons for living, school engagement] (If weak or unreliable, state explicitly.)

Mental Status Exam

• Appearance/behavior: [Observed appearance and behavior]
• Psychomotor: [Psychomotor activity]
• Speech: [Speech characteristics]
• Mood/Affect: [Mood in patient's words] / [Observed affect]
• Thought process/content: [Thought process and content]
• Perceptions: [Hallucinations, including whether command type]
• Insight/judgment: [Insight and judgment]
• Impulse control: [Impulse control assessment]
• Cooperation/engagement: [Cooperation and engagement, noting any minimization or inconsistency]

Clinical Formulation and Risk Level

Overall risk level: [low / moderate / high / imminent]

[Clinical rationale linking the assigned risk level to specific findings: ideation/plan/intent status, recent behaviors, access to means, key risk factors, key protective factors, and reliability of information; identify whether risk is primarily acute, chronic, or both]

• Key drivers of risk: [Proximal and distal contributors]
• Key mitigating factors: [Protective elements and engagement in care]

Caregiver Involvement and Supervision Plan

• Caregiver participation: [Name, relationship, what information was disclosed to them]
• Caregiver capacity: [Stated ability to supervise and implement restrictions; note any limitations]
• Supervision plan: [Who will supervise, where patient will stay, nighttime supervision arrangements, school-day plan if applicable, contingency if primary supervisor unavailable]

(If caregiver unavailable or unable to provide adequate supervision, document this and the mitigation taken.)

Safety Plan

[Statement that collaborative safety plan was created or reviewed and copy provided to patient and caregiver] (Do not use or document no-suicide contracts.)

• Warning signs/triggers: [In patient's own words when possible]
• Internal coping strategies: [Patient-identified strategies]
• People/places for distraction: [Identified supports]
• People to contact for help: [Names, roles, contact details]
• Crisis resources: [Professional and crisis resources with phone numbers]
• Means restriction steps: [With explicit caregiver roles and instructions for nighttime crises]

Disposition and Follow-Up

Disposition: [emergency psychiatric evaluation / inpatient admission / discharge with outpatient follow-up]

• Immediate actions completed: [Consultations obtained, observation orders, means restriction actions initiated, crisis resources provided]
• Follow-up plan: [Scheduled appointments or referrals with timeframe, warm handoff details if completed, planned follow-up contact by care team within 24–48 hours]
• Return precautions: [Specific symptoms or events that should trigger urgent reassessment and where to go or call]

Communications

(Include this section only when coordination occurred; omit if none.)

• [Date/time, person contacted, method, and outcome for each communication]
• Mandatory reports: [Agency and time] (If applicable.)
• Law enforcement: [Involvement and rationale] (If applicable.)