SAFETy Assessment

[date name="variable_1" default="02/05/2021"]
(1) Risk Factors(Note those that can be modified to reduce risk)
Suicidal Behavior
[checklist name="variable_1" value="None|Past attempts|Aborted attempts| Rehearsals | Self-Harm"]
Current/Past Psychiatric Diagnoses and Treatment
[textarea name="variable_1" default="sample text"]
Key Symptoms
[checklist name="variable_1" value="Anhedonia|Impulsivity|Hopelessness|Anxiety|Panic Attacks|Global Insomnia|Command Hallucinations"]
Family History of Suicidal Behavior
[checklist name="variable_1" value="None|History includes"]
[textarea name="variable_1" default="sample text"]
Change in Treatment
[checklist name="variable_1" value="Academic|Family|Relationship or Social|Reputational|Vocational|Major Loss|Major Trauma|Financial|Legal"]
Risk Behaviors
[checklist name="variable_1" value="None|Substance Abuse|Alcohol|Self-Harm|Inappropriate Sexual Behavior"]
Access to Weapons, sharps,meds(RX/OTC)
(2) Protective Factors (Note those that can be enhanced)
Internal
[checklist name="variable_1" value="Ability to Cope with Stress|Religious Beliefs|Fustration Tolerance|Absence of Psychosis"]
External
[checklist name="variable_1" value="Responsibility to family or pets|Positive Therapeutic Relationships|Social Supports"]
(3) Suicide Inquiry(suicidal thoughts, plans, behavior, and intent)
Ideation

Frequency
[select name="variable_1" value="Last 48 Hours____________
|Past Month_____________|Worse Ever______________"]
Intensity
[select name="variable_1" value="Last 48 Hours____________
|Past Month_____________|Worse Ever______________"]
Duration
[select name="variable_1" value="Last 48 Hours____________
|Past Month_____________|Worse Ever______________"]
Current Plan
[checklist name="variable_1" value="None|Timing|Location|Lethality|Availability|Preparatory"]
Behaviors
[checklist name="variable_1" value="None|Past Attempts|Aborted Attempts|Rehearsals|Self-Harm"]
Current Intent
[checklist name="variable_1" value="None|Expects to Carry out Plan|Believes Plan is Lethal|Believes Plan is Self-Injuries"]
Reason to Die
[text name="variable_1" default="sample text"]
Reasons for Live
[text name="variable_1" default="sample text"]

RISK LEVEL RISK/PROTECTIVE FACTOR SUICIDALITY POSSIBLE INTERVENTIONS

Risk/Protective Factors
[select name="variable_1" value="High-Psychiatric diagnoses with severe symptoms or acute precipitating event;protective factors not relevant|Moderate Multiple risk factors, few protectivefactors|Low Modifiable risk factors, strong protective factors"]

Suicidality
[select name="variable_1" value="High-Potentially lethal suicide attempt or persistent ideation with strong intent or suicide rehearsal| Moderate-Suicidal ideation with plan, but no intent or behavior|Low-Thoughts of death, no plan, intent, or behavior"]

Possible Interventions
[select name="variable_1" value="High-Admission generally indicated unless a significant change reduces risk. Suicide precautions|Moderate-Admission may be necessary depending on risk
factors. Develop crisis plan. Give emergency/crisis
numbers|Low-Outpatient referral, symptom reduction.
Give emergency/crisis numbers"]

(5)Document Treatment Plan
Risk/Protective Factors
[checklist name="variable_1" value="High|Moderate|Low"]
Suicidality
[checklist name="variable_1" value="High|Moderate|Low"]
Intervention Level
[checklist name="variable_1" value="High|Moderate|Low"]

Medications
[textarea name="variable_1" default="sample text"]

Suicide Precautions Advised
[select name="variable_1" value="Daily close monitoring and supervision|Ongoing consistent contact with safe individuals|restrict access to weapons(including firearms, knives, ropes, dangerous machinery) and medications(RX and OTC)|Counseled on supportive strategies to ensure safety and minimize conflict while arranging for further assessment or monitoring for response to treatment."]

Suicide Plan Provided
[textarea name="variable_1" default="sample text"]

Crisis Plan Developed with Patient
[textarea name="variable_1" default="sample text"]