Crisis Form

Crisis Form
This Rating Scale will help to establish the risk of suicide of an individual. Ask the individual consider the past month as a whole when answering.
What is the individual's first and last name?
1. Wish to be Dead:

Person endorses thoughts about a wish to be dead or not alive anymore, or wish to fall asleep and not wake up.
Have you wished you were dead or wished you could go to sleep and not wake up?
1. Please explain:
2. Non-Specific Active Suicidal Thoughts:

General non-specific thoughts of wanting to end one's life/die by suicide without general thoughts of method, intent, or plan.
Have you had any thoughts of killing yourself?
2. Please explain:
3. Active Suicidal Ideation with Any Methods/Means (Not Plan) without Intent to Act:

Person endorses thoughts of suicide and has thought of at least one method.

EX: "I thought about taking an overdose but I never made a specific plan as to when, where or how I would actualy do it....and I would never go through with it."
Have you been thinking about (how) you might do this?
3. How? (means)
Do you have access to the methods/means?
4. Active Suicidal Ideation with Some Intent to Act, without Specific Plan:

Active suicidal thoughts of killing oneself and reports having some intent to act on such thoughts.

EX: "I have the thoughts but I definitely will not do anything about them."
Have you had these thoughts and had some intention of acting on them?
4. Please Explain:
5. Active Suicidal Ideation with Specific Plan and Intent:

Thoughts of killing oneself with details of plan fully or partially worked out and person has some intent to carry it out.
Have you started to work out or worked out the details of how to kill yourself?
Do you intend to carry out this plan?
Do you have a timeframe (when)?
Do you have a location (where)?
6. Preparatory Acts or Behavior:

Examples: Collected pills, obtained a gun, gave away valuables, wrote a will or suicide note, took out pills but didn’t swallow any, held a gun but changed your mind or it was grabbed from your hand, went to the roof but didn’t jump; or actually took pills, tried to shoot yourself, cut yourself, tried to hang yourself, etc.
Have you done anything, started to do anything, or prepared to do anything to end your life? (Over their entire lifetime)
6. Please Explain:
Was this within the past 3 months?
Crisis Information
Who made contact?
Person in Crisis Phone
Please enter a valid phone number.Format: (000) 000-0000.
Person in Crisis Email
example@example.com
Date of Contact

MonthDayYear
Date
Crisis Notes
Please enter any relevant notes for the individual
Crisis Score
Should be Empty:

Crisis Form

This Rating Scale will help to establish the risk of suicide of an individual. Ask the individual consider the past month as a whole when answering.

1. Wish to be Dead:

2. Non-Specific Active Suicidal Thoughts:

3. Active Suicidal Ideation with Any Methods/Means (Not Plan) without Intent to Act:

4. Active Suicidal Ideation with Some Intent to Act, without Specific Plan:

5. Active Suicidal Ideation with Specific Plan and Intent:

6. Preparatory Acts or Behavior:

Crisis Information