CMH – Suicide Risk Report

Suicide Risk Report for [text name="Name"]
Date: [text name="date"]


Pt reported they are [checkbox value="not|actively|passively"] suicidal, with [checkbox value="no|firm|vague|lethal|nonlethal|undisclosed"] plans to end their life. The patient verbally confirmed they [checkbox value="have no intention to suicide|intend to die|have ambivalent feelings about suicide"].


The patient reported they [select value="do not feel|feel"] like giving up on life. Their future seems [select name="variable_1" value="hopeful|hopeless"] and their life [select name="variable_2" value="does not seem|seems"] so bad that they wish to die. They further reported [checkbox name="freq" value="no suicidal thoughts.|having suicidal thoughts"][conditional field="freq" condition="(freq).is('having suicidal thoughts')"] [checkbox value="infrequently|most days|every day"], and rated these thoughts as [checkbox value="mild|moderate|severe"] in their intensity. When asked about having suicidal plans, the patient reported [checkbox value="no plans|vague ideas about it|having a definite plan|they are unwilling to discuss it"]. When further asked about how close have they been to acting on these thoughts in the past, the patient reported [checkbox value="not close at all|very close|they did indeed attempt suicide|they do not wish to discuss it"]. When asked how certain they feel about acting on these thoughts in the future, the patient reported [checkbox value="it's unlikely|they weren't sure|they were absolutely certain|they did not wish to discuss it"] Finally, when I asked about having access to the means to suicide, the patient reported [checkbox value="no|yes possibly|yes absolutely"][/conditional]

[checkbox name="prosu" value="-- PROTECTIVE FACTORS --"][conditional field="prosu" condition="(prosu).is('-- PROTECTIVE FACTORS --')"] 

[checkbox value="treatment responsiveness|connectedness to individuals, family, community, and social institutions|problem-solving skills|coping skills|ability to adapt to change|they sense of purpose or meaning in life Cultural, religious, or personal beliefs that discourage self-injury|good social skills|ability to manage feelings of anger|good health|access to mental and physical health care|healthy fear of risky behaviours and pain|hope for the future and optimism|sobriety|medical compliance|a sense of the importance of health and wellness|impulse control|they strong sense of self-worth or self-esteem|a sense of personal control or determination|access to a variety of clinical interventions and support for seeking help|resiliency|expressed reasons for living|being married|being a parent|strong relationships, particularly with family members|opportunities to participate in and contribute to school or community projects and activities|living in a reasonably safe and stable environment|having restricted access to lethal means|sense of responsibility and duty to others|being a pet owner"][/conditional]

[checkbox name="stat" value="-- STATIC RISK FACTORS --"][conditional field="stat" condition="(stat).is('-- STATIC RISK FACTORS --')"] 

[checkbox value="Hx of denying the need for service contact|Hx of avoiding of service contact|non-responsiveness to pharmacological treatment|non-responsiveness to psycho-social interventions|recent discharge from a psychiatric facility|chronic stressors|a history of self-harm|a history of previous suicide attempts|previous hospitalization for suicidality|previous hospitalization for self-harm|Hx of psychiatric illness|Hx of substance abuse|unstable personality structure|a background of childhood adversity|having a family history of suicide|divorced|demographic - male - single age 35-64|problem-solving difficulties|Hx of impulsive behavior|Hx of reckless and self-endangering behaviors|Absolutistic thinking|Tunnel vision|Limited capacity for
self-­-soothing|Perfectionism|sexual orientation rejected by family|Guns
in the home|access to abundant medications|chronic medical illness|chronic pain"][/conditional]

[checkbox name="acute" value="-- ACUTE RISK FACTORS --"][conditional field="acute" condition="(acute).is('-- ACUTE RISK FACTORS --')"] 

[checkbox value="current suicidal ideation|current suicidal plan|plan lethality|preparation behahiours|vocalising threat to suicide|rehearsal behaviours|recent suicide attempt|regrets not dying|acute mood disorder|current substance abuse|increased substance abuse|mood lability|suicide command hallucinations|insomnia|persistent nightmares|unremitting pain|persistent distress|persistent agitation|tearful|guarded|withdrawal from services|comorbid MH concerns|feelings of hopelessness|severe anhedonia|severe depression|loss of self-esteem|feelings of shame|feeling intolerably alone|feeling trapped|no reasons for living|loss of purpose and meaning|increased impulsivity|increased recklessness|increased anger|seeking revenge|recent violent behaviours|final act behaviours|stalking|intense jealousy over ex|recent loss of relationship|loss of social support|recent discharge from MHIPU|loss of job|financial pressure|loss of status|suicide of close friend|declining health|pending legal issues|pending criminal charges|being victimised"][/conditional]

[checkbox name="Dyna" value="-- DYNAMIC RISK FACTORS --"][conditional field="Dyna" condition="(Dyna).is('-- DYNAMIC RISK FACTORS --')"] 

[checkbox value="untreated mental illness|suicidal thinking|homelessness|personality disorder|lack of distress tolerance skills|lack of therapeutic alliance|has access to lethal means|withdrawal from support groups|treatment compliance|abuse of substances|psycho-social stressors|problem-solving|feelings of hopelessness|feelings of anger|lack of professional skills|unmet needs"][/conditional].


[checkbox value="hospitalization for imminent risk for suicide|immediate assessment with MH professional|remove lethal means|monitoring by family / friends|inform family of risk|recommended treatment of MH Sx|recommend D&A treatment service|help Pt improving their coping strategies|challenging negative beliefs|emphasize behavioral control|behavioural activation|increase pleasant activities|provide suicide crisis plan: call XXX or present to ED after hours|call Crisis Team after hours contact number or CMH number to call during business hours|PRN medications|alert supportive individuals|increase psychosocial supports|Encourage reality-testing with family, friends or professionals|provide thought interruption strategies|after-hours numbers to call|Written safety plan"]
Suicide Risk Report for


Pt reported they are suicidal, with plans to end their life. The patient verbally confirmed they .


The patient reported they like giving up on life. Their future seems and their life so bad that they wish to die. They further reported



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Sandbox Metrics: Structured Data Index 0.92, 29 form elements, 61 boilerplate words, 2 text boxes, 19 checkboxes, 3 drop downs, 5 conditionals, 189 total clicks
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