Suicide Risk Screening Tool

Name*

First NameLast Name

Date of Birth*

Date

In the past few weeks, have you wished you were dead?

YesNo

In the past few weeks, have you felt that you or your family would be better off if you were dead?

YesNo

In the past week, have you been having thoughts of killing yourself?

YesNo

Have you ever tried to kill yourself?

YesNo

If yes, when and how? Please explain.

Are you having thoughts of killing yourself right now?

YesNo

If yes, please explain:

Next steps:
• If patient answers “No” to all questions 1 through 4, screening is complete (not necessary to ask question #5).
No intervention is necessary (*Note: Clinical judgment can always override a negative screen).
• If patient answers “Yes” to any of questions 1 through 4, or refuses to answer, they are considered a
positive screen. Ask question #5 to assess acuity:

___ “Yes” to question #5 = acute positive screen (imminent risk identified)
• Patient requires a STAT safety/full mental health evaluation.
Patient cannot leave until evaluated for safety.
• Keep patient in sight. Remove all dangerous objects from room. Alert physician or clinician
responsible for patient’s care.

___ “No” to question #5 = non-acute positive screen (potential risk identified)
• Patient requires a brief suicide safety assessment to determine if a full mental health evaluation
is needed. If a patient (or parent/guardian) refuses the brief assessment, this should be treated
as an “against medical advice” (AMA) discharge.
• Alert physician or clinician responsible for patient’s care.

Provide resources to all patients
• 24/7 National Suicide Prevention Lifeline, 988
• 24/7 Crisis Text Line: Text “HOME” to 741741

Signature*

Date*

Date