Safety/Risk Assessment & Safety Plan (Child/Adolescent Therapy)

Header

Date/Time: [Encounter date and time]

Duration: [Total minutes spent]

Modality: [in-person / video / phone]

Setting: [Clinic / Home / School / ED / Other]

Note Context: [Standalone encounter / Addendum] (If addendum, cross-reference the associated therapy encounter: date, clinician, location.)

Participants and Informants

[Individuals present and roles] (List patient, parent/guardian, caregivers, interpreter, and others present; include names/titles when appropriate.)

[Private time with adolescent: occurred / did not occur] (If not, document reason such as guardian declined to leave or youth requested guardian remain.)

[Collateral sources contacted] (List who was contacted, method, and whether consent/ROI is in place.)

Reason for Safety Evaluation

[Triggering event or concern] (Briefly describe what prompted today's assessment: positive screen, patient disclosure, caregiver/school report, recent crisis event, behavioral escalation.)

[Time course and immediate context] (Onset, recency, setting, precipitating stressors.)

[Youth's framing of the concern] (Include a brief quote if provided.)

Confidentiality and Guardian Involvement

[Confidentiality reviewed/reaffirmed and limits discussed]

[Risk disclosure process: youth disclosed with support / clinician disclosed with youth present / clinician disclosed without youth present] [Information shared]

[Guardian notification today: yes / no] [Response] [Ability and willingness to implement safety measures] [Barriers if any] (Note custody issues, caregiver unavailability, or unsafe home dynamics if relevant.)

Suicide and Self-Harm Risk Assessment

(Include this section when suicide or self-harm is a concern. If screening is negative and youth denies concerns, condense to a brief statement confirming key domains were assessed. Use explicit language for each domain: Denied / Endorsed / Unknown / Not assessed with reason. Attribute information to source.)

• Screening: [Tool used] [Mode: verbal / written / electronic] [Result and risk classification] [Interpretation]
• Ideation: [Passive SI: Denied / Endorsed / Unknown / Not assessed] [Active SI: Denied / Endorsed / Unknown / Not assessed] [Frequency, intensity, triggers, controllability if endorsed]
• Plan: [Plan: Denied / Endorsed / Unknown / Not assessed] [Method category, timing, location, preparatory steps if endorsed]
• Intent: [Desire to die vs. escape] [Ambivalence] [Stated intent level]
• History: [Prior suicide attempts: count, approximate dates, severity] [Aborted or interrupted attempts] [Prior hospitalizations for suicidality]
• Nonsuicidal Self-Injury: [Presence / Absence] [Methods, frequency, function, relationship to suicidal thinking if present]
• Warning Signs: [Youth-specific early warning signs of escalation] (List concrete signs such as sleep loss, isolation, agitation, conflict.)
• Risk Factors: [Static factors] [Dynamic factors]
• Protective Factors: [Internal] [Relational] [Environmental]
• Means Access: [Firearms in any residence: yes / no / unknown] [Storage status] [Medications access and storage] [Sharps, ligatures, other hazards] (If unknown, document why and plan to verify. If conflicting reports between youth and caregiver, document both and treat as access-present until verified.)

Violence and Aggression Risk Assessment

(Include only when homicidal ideation, threats, or aggression concerns are present. Use explicit language: Denied / Endorsed / Unknown / Not assessed. Document observable facts and direct quotes for salient threats.)

• Ideation and Threats: [HI: present / absent] [Frequency, triggers] [Leakage via texts, social media, writings, verbal statements: yes / no / unknown]
• Targeting: [Identifiable target: yes / no / unknown] [Proximity and access to target]
• Plan and Preparation: [Plan: present / absent] [Rehearsal, stalking behavior, acquisition attempts]
• History: [Prior violence, cruelty to animals, fire setting, weapon carrying, fights, legal or school consequences]
• Weapon Access: [Firearms in any residence: yes / no / unknown] [Other weapons] [Supervision and storage controls]
• Modifiers: [Psychosis, mania, intoxication, agitation, impulse control] [Protective factors including supervision and willingness to accept help]

Mental Status Relevant to Risk

(Focus on risk-relevant domains; document observations.)

• [Appearance, behavior, engagement]
• [Psychomotor status]
• [Affect, mood, hopelessness]
• [Thought content: SI, HI, violent themes]
• [Psychosis indicators: hallucinations, delusions, command experiences]
• [Judgment, insight, impulse control]
• [Intoxication or withdrawal concerns]
• [Ability to collaborate in safety planning]

Risk Formulation and Level

[Formulation summary] (Concise synthesis explaining why acute risk is present or absent, distinct from baseline risk. Identify top drivers and key protective buffers.)

• Acute suicide/self-harm risk (next 24–72 hours): [low / moderate / high] [Rationale]
• Baseline/chronic suicide/self-harm risk: [low / moderate / high] [Rationale]
• Violence/aggression risk: [N/A / low / moderate / high] [Rationale] (Include only if assessed above.)

[Risk-to-plan linkage] (Explicitly link risk level to mitigation: supervision, means-safety actions, crisis resources, follow-up timing, level of care.)

Interventions Completed

• Safety Planning: [Created / Updated / Reviewed] [With whom] [Format provided: paper / portal / photo] [Shared with caregiver: yes / no]
• Means-Safety Counseling: [Topics covered] [Specific actions agreed upon and by whom] [Timeframe] [Verification plan]
• Supervision Plan: [Who will supervise] [Daytime and nighttime arrangements] [School-day plan] [Plans for each residence if multiple homes]
• Care Coordination: [Contacts made] [Consultation obtained] [Shared decisions]
• Disposition: [Outpatient with safety plan / Urgent evaluation / ED referral / Admission] [Transportation if applicable] (If higher level of care was recommended but declined, document discussion, alternatives offered, and safety measures implemented.)

Safety Plan

(Collaboratively written in youth's language, developmentally appropriate, ordered from independent coping to emergency actions.)

Step 1: Warning Signs

• [Personalized warning sign]
• [Personalized warning sign]
• [Personalized warning sign] (2–5 items)

Step 2: Internal Coping Strategies

• [Immediate strategy youth can do alone]
• [Immediate strategy youth can do alone]
• [Immediate strategy youth can do alone] (2–5 items; ensure feasible at home, school, bedtime)

Step 3: Social Distractions

• [Safe activity, place, or person for distraction with contact or location]
• [Safe activity, place, or person for distraction]
• [Safe activity, place, or person for distraction] (2–5 items)

Step 4: People to Ask for Help

• [Trusted adult or peer: name, role, contact] [Brief script if helpful]
• [Trusted adult or peer: name, role, contact]
• [Trusted adult or peer: name, role, contact] (2–5 items)

Step 5: Crisis Resources

• [Treating clinician: hours and after-hours instructions]
• [Local crisis line: number and availability]
• [988 Suicide and Crisis Lifeline: call, text, or chat]
• [Nearest ED and when to go]
• [When to call 911]

Step 6: Making the Environment Safer

• [Specific means-safety action with assigned ownership and timeframe]
• [Specific means-safety action with assigned ownership and timeframe]
• [Specific means-safety action with assigned ownership and timeframe] (2–5 actions)

Caregiver Responsibilities

• [Youth-specific warning signs caregiver will watch for]
• [How caregiver will respond: validation, reduce access, increase supervision, contact supports]
• [Time-limited safety agreements about monitoring and supervision]

Follow-Up Plan

• [Next appointment date and time or scheduling plan]
• [Interim check-ins or caring contacts: method and timing]
• [Referrals placed with expected timelines]
• [Materials provided to youth and family: safety plan copy, crisis resources, after-visit summary]

(Documentation guidance: Use non-stigmatizing language—"died by suicide," "suicide attempt," "suicidal thoughts," "nonsuicidal self-injury." Attribute information to sources. When information conflicts, document both and treat means access as present until verified. For high-risk domains, never leave blanks. If child cannot answer due to age or limitations, document attempts, collateral obtained, and safety actions taken despite uncertainty. Do not document "no-suicide contracts"; use collaborative safety planning instead.)