Suicide Risk Report for [text name="Name"]
Date: [text name="date"]
-- SUICIDE RISK SUMMARY --
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"].
-- PATIENT REPORT --
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].
- RISK MANAGEMENT RECOMMENDATIONS for PATIENT--
[checkbox value="hospitalization for imminent risk for suicide|immediate assessment with MH professional|removing lethal means|monitoring by family / friends|informed family of risk|recommended treatment of MH Sx|recommended D&A treatment service|help Pt improving their coping strategies|challenging negative beliefs|emphasizing behavioral control|behavioural activation|increase pleasant activities|provided suicide crisis plan: call 000 or present to ED after hours|provided suicide assessment plan: call ACS after hours or CMH during business hours|PRN medications|alerting supportive individuals|increase psycho-social supports|Encourage reality-testing with family, friends or professionals|provide interruption strategies|after hours numbers provided|Written safety plan provided"]
-- SUICIDE SAFETY PLAN for PATIENT --
Make Your Environment Safe:
Plan what steps you can take to make yourself safe. This may involve removing or securing any items that you are likely to use to hurt yourself, or going to another location until the urges have passed. It may also involve getting another person involved to help you.
Warning signs (thoughts, images, mood, situation, behavior) that a crisis may be
People that provide distraction:
People whom I can ask for help:
Professionals or agencies I can contact during when my risk is increasing:
1 Lismore Acute Care Team 6620 2323 (4:30pm-10pm Weeknights all day Sat & Sun)
2 Mental Health Access Line 1800 011 511
3 Duty Officer 9:30am-4:30pm 6620 2300
Steps during a crisis:
1 Go to the nearest ED if possible
2 Request family or friend take you to ED if you're unable to get there
3 Call 000 if unable to attend ED
4 Request family or friend call 000 if unable to call yourself
The one thing that is most important to me and worth living for is:
-- DISTRACTION TECHNIQUES --
• Slash an empty plastic drink bottle
• Rip up old clothing
• Slash a piece of heavy cardboard
• Squeeze ice
• Do something that will give you a sharp sensation, like eating lemon
• Make a soft cloth doll to represent the things you are angry at. Cut and tear it instead of yourself
• Flatten aluminium cans for recycling
• Hit a punching bag
• Exercise and listen to angry music
• Break junk up with a hammer
• Rip up an old newspaper or phone book
• On a sketch or photo of yourself, mark in red ink what you want to do. Cut and tear the picture.
• Make clay models and cut or smash them
• Throw ice against a brick wall hard enough to shatter it
• Bang pots and pans
• Stomp around in heavy shoes
• Play sport
• Play video games
Feeling sad or depressed:
• Do something slow and soothing
• Take a hot bath with bath oil or bubbles
• Curl up under a soft blanket with hot cocoa and a good book
• Baby yourself somehow
• Give yourself a present
• Hug a loved one or stuffed animal
• Play with a pet
• Make a list of things that make you happy
• Do something nice for someone else
• Light sweet-smelling incense
• Listen to soothing music
• Smooth nice body lotion into the parts of yourself you want to hurt
• Call a friend and just talk about things that you like
• Make a tray of special treats
• Watch TV or read
• Visit a friend
Craving sensation/Feeling empty or unreal:
• List the many uses for a random object. (For example, what are all the things you
can do with a twist-tie?)
• Interact with other people
• Put a finger into a frozen food (like ice cream)
• Bite into a hot pepper or chew a piece of ginger root
• Rub vicks under your nose
• Slap a tabletop hard
• Take a cold shower
• Stomp your feet on the ground
• Focus on how it feels to breathe
• Notice the way your chest and stomach move with each breath
• Do a task that is exacting and requires focus and concentration.
Eat a raisin mindfully. Notice how it looks and feels. Try to describe the texture. How does a raisin smell? Chew slowly, noticing how the texture and even the taste of the raisin change as you chew it.
• Choose an object in the room. Examine it carefully and then write as detailed a description of it as you can.
• Choose a random object, like a twist-tie, and try to list 30 different uses for it.
• Pick a subject and research it on the web.
Feeling guilty or like a bad person:
• List as many good things about yourself as you can.
• Read something good that someone has written about you.
• Talk to someone that cares about you.
• Do something nice for someone else.
• Remember when you’ve done something good.
• Think about why you feel guilty and how you might be able to change it.
• Write down your feelings in a diary.
• Write a story
• Talk to a counsellor
• Draw or color.
• Make yourself laugh (pull faces in the mirror and talk in a weird voice)
• Start a blog – perhaps you can write about how you get through difficult times to help others going through similar experiences.
• Make a playlist of songs that can help you – these can be sad, happy or uplifting songs.
• Learn a new song – listen to it on repeat until you have learnt the lyrics off by heart.
• Make a Hope Book or a Hope Box – see our resources for ideas on this.
• Decorate your room.
• Try cooking or baking a new recipe.
• Play with kinetic sand – mould it, shape it or cut it up.
• Make shapes using weavesilk.com – also available on iOS and Android. Other interactive distractions can be found at neave.com
• Play a game.
• Listen to music.
• Take a shower.
• Open a dictionary and
learn new words.
• Do homework.
• Dig in the garden.
• Watch a feel-good movie.
Do Something Mindful
• Count down slowly from 10 to 0.
• Breathe slowly, in through the nose and out through the mouth.
• Focus on objects around you and thinking about how they look, sound, smell, taste and feel.
• Do yoga.
• Learn some breathing exercises to aid relaxation.
• Concentrate on something that makes you happy: good friends, good times, laughter, etc.
• Watch ASMR videos on YouTube
-- COPING STATEMENTS FOR PATIENT --
Stop, and breathe, I can do this
This will pass
I can be anxious/angry/sad and still deal with this
I have done this before, and I can do it again
This feels bad, it is a normal body reaction. It will pass
This feels bad, and feelings are very often wrong
These are just feelings, they will go away
This won`t last forever
Short term pain for long term gain
I can feel bad and still choose to take a new and healthy direction
I don`t need to rush, I can take things slowly
I have survived before, I will survive now
I feel this way because of my past experiences, but I am safe right now
I'm stronger than I think
It`s okay to feel this way, it`s a normal reaction
Right now, I am not in danger. Right now, I`m safe
My mind is not always my friend
Thoughts are just thoughts. They are not necessarily true or factual
I will learn from this experience, even if it seems hard to understand right now
This is difficult and uncomfortable, but it is only temporary
I choose to see this challenge as an opportunity
I can use my coping skills and get through this
I can learn from this and it will be easier next time
Keep calm and carry on