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Suicide Check List, Risk Factors for Suicide,
and Action & Care Plan

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.

 

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