C-SSRS Screening Form
Columbia-Suicide Severity Rating Scale (Screen Version) for clinical suicide risk assessment. Please answer the following questions as they apply to the selected time frame.
Clinician Administering CSRS
Email of Clinician Administering CSRS
example@example.com
Clinical Supervisor of Clinician or N/A if none
Email of Clinical Supervisor if any
example@example.com
Full name of client
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Read questions as written; record responses
1. Have you wished you were dead or wished you could go to sleep and not wake up?
YES
NO
2. Have you actually had any thoughts of killing yourself?
YES
NO
If YES to 2, ask questions 3, 4, 5, and 6. If NO to 2, go directly to question 6.
3. Have you been thinking about how you might kill yourself?
YES
NO
4. Have you had these thoughts and had some intention of acting on them?
YES
NO
5. Have you started to work out or worked out the details of how to kill yourself? Do you intend to carry out this plan?
YES
NO
6. Have you ever done anything, started to do anything, or prepared to do anything to end your life?
YES
NO
Timing
How long ago did you do any of these?
Over a year ago
Between three months and a year ago
Within the last three months
Time Frame
Please Select
Past Month
Since Last Visit
Submit
Should be Empty: