Suicide Risk Assessment & Patient-Facing Safety Plan Note

CLINICIAN-FACING ASSESSMENT

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

Setting: [ED / inpatient / outpatient / urgent care]

Modality: [in-person / phone / video]

Evaluator: [Evaluator name, credentials, role]

Participants: [Patient; caregivers present; collateral contacts; interpreter if used]

Reason for Assessment: [Reason for assessment]

Presenting Concern and Context

[Patient-stated concern with brief direct quote if useful; immediate precipitant(s) and timeline; current stressors; relevant context informing risk formulation] (Keep focused on information relevant to risk assessment. Omit extended psychosocial history unless directly relevant.)

Screening Results

[Instrument name, timeframe assessed, result, action taken if positive] (Omit this section entirely if no screening tool was used. If screening could not be completed, document the reason.)

Suicide Inquiry

• Current Suicidal Ideation: [Passive death wish / active suicidal ideation / denies]; [Frequency, duration, intensity, controllability; most recent occurrence; current status; reasons to die vs reasons to live] (If patient denies SI, document denial and note any incongruence with behaviors or collateral.)
• Plan: [Present / absent]; [If present: method category, timing, location, preparation level] (Describe sufficiently to assess lethality and feasibility.)
• Intent: [Intends to act / might act / no intent]; [Expectation of acting; ambivalence]
• Prior Behaviors: [Suicide attempts with approximate dates, methods, medical severity, rescue circumstances; aborted/interrupted attempts; preparatory behaviors; non-suicidal self-injury with methods, function, and course] (Note if information is unknown or not assessed.)
• Lethal Means Access: [Firearms: presence, location, storage, access level; Medications: stockpiles, high-risk meds, access to others' meds; Other relevant means] (Always document explicitly. If patient refuses or cannot answer, state this and note impact on risk planning. Never infer absence without documented inquiry.)

Risk and Protective Factors

Risk Factors:

• [Relevant static and dynamic risk factors]

Protective Factors:

• [Credible protective factors with source noted when relevant]

(Avoid overstating protective factors.)

Mental Status (Safety-Relevant)

• Appearance/Behavior: [Brief description]
• Mood/Affect: [Brief description]
• Thought Content: [Hopelessness, psychosis, command hallucinations, other safety-relevant content]
• Cognition: [Intoxication, withdrawal, delirium if applicable; orientation/attention if relevant]
• Insight/Judgment: [Brief description]
• Impulsivity: [Brief description]
• Interview Reliability: [Reliable / limited / questionable]; [Factors affecting reliability]

Risk Level and Formulation

Risk Level: [Low / moderate / high] or [Acute / chronic] (Use institutional taxonomy.)

Rationale: [Key drivers of risk determination; how protective factors and mitigation influence current risk; relevant uncertainties such as limited collateral, patient reluctance, or conflicting information] (Avoid relying on phrases like "contracted for safety" without describing actual mitigation steps.)

Interventions Completed

• Safety Planning Intervention: [Completed / not completed]; [Completed with patient / caregiver / both] (If incomplete, document reason and interim safety measures.)
• Lethal Means Counseling: [Completed / declined / not feasible]; [Specific actions agreed upon—who will do what, by when]
• Crisis Resources: [Reviewed and provided in writing / declined]; [Materials provided and modality]
• Family/Caregiver Involvement: [Involved / not involved / unavailable]; [Roles assigned and instructions provided]
• Coordination with Other Services: [Consults, referrals, community resources, care coordination]
• Medication Safety Actions: [Prescribing changes, dispense quantities, supervised administration] (Omit if not applicable.)
• Declined Interventions: [What was recommended; patient's reason; alternatives offered; impact on disposition] (Omit if none declined.)

Disposition and Follow-Up

Disposition: [Decision with justification linked to risk formulation]

Follow-Up: [Appointments scheduled or pending; responsible party; warm handoff details; caring contact plan if applicable]

Return Precautions: [Thresholds for calling emergency services or presenting to ED, documented as reviewed with patient]

(If follow-up could not be arranged, document barriers and contingency plan.)

---

PATIENT-FACING SAFETY PLAN

(Use clear, supportive, non-clinical language suitable for printing or portal sharing. Use patient's own words when available. Leave steps sparse if information is unavailable rather than fabricating content.)

Date Created: [Date]

Created with: [Names of people who helped create this plan]

Step 1: My Warning Signs

• [Warning sign 1]
• [Warning sign 2]
• [Warning sign 3]

(Thoughts, feelings, behaviors, or situations that signal a crisis may be building.)

Step 2: Things I Can Do On My Own

• [Coping strategy 1]
• [Coping strategy 2]
• [Coping strategy 3]

(Actions I can do within 10–20 minutes without needing anyone else.)

Step 3: People and Places That Help Me Feel Better

• [Person or place — phone number or location]
• [Person or place — phone number or location]
• [Person or place — phone number or location]

(For distraction and connection; I do not have to talk about the crisis.)

Step 4: People I Can Ask for Help

• [Name — phone/text — what I can say when I reach out]
• [Name — phone/text — what I can say when I reach out]
• [Name — phone/text — what I can say when I reach out]

Step 5: Professionals and Crisis Resources

• My clinician/clinic: [Name and phone]; [After-hours instructions]
• Local crisis resource: [Name and phone]; [Hours/instructions]
• 988 Suicide & Crisis Lifeline: Call or text 988 (available 24/7)
• Emergency: If I feel I cannot stay safe, I will call 911 or go to the nearest Emergency Department.

Step 6: Making My Environment Safer

• [Specific action — who will do what, by when]
• [Specific action — who will do what, by when]

(These are temporary steps to reduce risk until I am feeling safer.)

Reasons to Live

• [Reason 1]
• [Reason 2]
• [Reason 3]

(Omit this section if not discussed or patient prefers not to include.)

Where I Will Keep This Plan: [Location(s)]

Who Has a Copy: [Names/relationships]