BRTC Imminent Suicide Risk and Treatment Actions Note
COLUMBIA-SUICIDE SEVERITY RATING SCALE (C-SSRS)?Posner, Brent, Lucas, Gould, Stanley, Brown, Fisher, Zelazny, Burke, Oquendo, & Mann? 2008 The Research Foundation for Mental Hygiene, Inc.RISK ASSESSMENTInstructions: Check all risk and protective factors that apply. To be completed following the patient interview, review of medical record(s) and/or consultation with family members and/or other professionals.Past 3 MonthsSuicidal and Self-Injurious BehaviorLifetimeClinical Status (Recent) FORMCHECKBOX Actual suicide attempt FORMCHECKBOX Lifetime FORMCHECKBOX FORMCHECKBOX Hopelessness FORMCHECKBOX Interrupted attempt FORMCHECKBOX Lifetime FORMCHECKBOX FORMCHECKBOX Major depressive episode FORMCHECKBOX Aborted or Self-Interrupted attempt FORMCHECKBOX Lifetime FORMCHECKBOX FORMCHECKBOX Mixed affective episode (e.g. Bipolar) FORMCHECKBOX Other preparatory acts to kill self FORMCHECKBOX Lifetime FORMCHECKBOX FORMCHECKBOX Command hallucinations to hurt self FORMCHECKBOX Self-injurious behavior without suicidal intent FORMCHECKBOX FORMCHECKBOX Highly impulsive behaviorSuicidal IdeationCheck Most Severe in Past Month FORMCHECKBOX Substance abuse or dependence FORMCHECKBOX Wish to be dead FORMCHECKBOX Agitation or severe anxiety FORMCHECKBOX Suicidal thoughts FORMCHECKBOX Perceived burden on family or others FORMCHECKBOX Suicidal thoughts with method (but without specific plan or intent to act) FORMCHECKBOX Chronic physical pain or other acute medical problem (HIV/AIDS, COPD, cancer, etc.) FORMCHECKBOX Suicidal intent (without specific plan) FORMCHECKBOX Homicidal ideation FORMCHECKBOX Suicidal intent with specific plan FORMCHECKBOX Aggressive behavior towards othersActivating Events (Recent) FORMCHECKBOX Method for suicide available (gun, pills, etc.) FORMCHECKBOX Recent loss(es) or other significant negative event(s) (legal, financial, relationship, etc.) FORMCHECKBOX Refuses or feels unable to agree to safety planDescribe: FORMCHECKBOX Sexual abuse (lifetime) FORMCHECKBOX Family history of suicide (lifetime) FORMCHECKBOX Pending incarceration or homelessnessProtective Factors (Recent) FORMCHECKBOX Current or pending isolation or feeling alone FORMCHECKBOX Identifies reasons for livingTreatment History FORMCHECKBOX Responsibility to family or others; living with family FORMCHECKBOX Previous psychiatric diagnoses and treatments FORMCHECKBOX Supportive social network or family FORMCHECKBOX Hopeless or dissatisfied with treatment FORMCHECKBOX Fear of death or dying due to pain and suffering FORMCHECKBOX Non-compliant with treatment FORMCHECKBOX Belief that suicide is immoral; high spirituality FORMCHECKBOX Not receiving treatment FORMCHECKBOX Engaged in work or schoolOther Risk FactorsOther Protective Factors FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Describe any suicidal, self-injurious or aggressive behavior (include dates) ................
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