Suicide Risk Assessment Form

Patient Information

Name Date of Birth Patient ID / MRN

Current Status

Reason for Assessment Presenting Problem/Concern

Suicidal Thoughts

Has the patient expressed suicidal thoughts? Yes No If yes, provide details (frequency, duration, intensity):

Plan & Intent

Does the patient have a plan? Yes No Does the patient have intent to act on the plan? Yes No Plan Details:

History

Any history of suicide attempts? Yes No Any history of self-harm? Yes No Family history of suicide? Yes No

Protective Factors

List any protective factors (e.g., family support, reasons for living):

Clinician Assessment

Risk Level Low Moderate High Clinical Impression / Comments