Suicide Risk Screening Tool

Suicide Risk Screening Tool
Name

First NameLast Name
Date

MonthDayYear
Date
1. In the past few weeks, have you wished you were dead?

YesNo
2. In the pas few weeks have you felt that you or your family would be better off if you wer dead?

YesNo
3. In the past week, have you been having thoughts about killing yourself?

YesNo
4. Have you ever tried to kill yourself?

YesNo
If yes how?
When?
If you answered YES to any of the above questions, continue to question 5:
5. Are you having thoughts of killing yourself right now?

YesNo
If yes, please describe:
Resources:

24/7 National Suicide Prevention Lifeline 1-800-273-TALK (8255)

24/7 Crisis Text Line: Text "HOME" to 741-741
Should be Empty: