Assessment & Plan Elements
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Mental Health History
Previous Mental Health History
[select name="variable_1" value="yes|no|unknown|n/a"]

Previous Outpatient Treatment
[select name="variable_1" value="yes|no|unknown|n/a"]

Provider Name(s) & Approximate Dates: ??
Intervention/Response: ??
Previous Outpatient Treatment
[select name="variable_1" value="yes|no|unknown|n/a"]

Psychiatric Hospitalizations
[select name="variable_1" value="yes|no|unknown|n/a"]

Hospital Name(s) and Approximate Dates: ??
[textarea name="variable_1" default="??"]

Notes: ??[textarea name="variable_1" default="??"]

Suicide Risk Assessment:
Previous Suicide Attempt [select name="variable_1" value="yes|no|unknown|n/a"]

When, where, how hospitalized:[textarea name="variable_1" default="??"]

******Warning Signs
[checklist name="variable_1" value="Threatening to hurt or kill self|Seeking means to kill self (attempts to acquire pills, weapons, other means)|Talking or writing about death, dying or suicide|Hopelessness|Rage, anger, seeking revenge|Acting reckless or engaging in risky activities|Feeling trapped|Increased alcohol or drug use|Withdrawing from friends, family, society|Anxiety, agitation|Unable to sleep|Sleeping all the time|Dramatic changes in mood|No reason for living, no sense of purpose in life"]


******Risk Factors
[checklist name="variable_1" value="Psychiatric co-morbidity|Physical disorder/chronic condition|Traumatic brain injury|Previous suicide attempt|Alcohol/substance use|Current or previous psychiatric dx|Impulsivity and poor self-control|Hopelessness|Recent loss|Recent discharge from inpatient psychiatric unit|Family history of suicide|History of abuse: Physical|History of abuse: Sexual|History of abuse: Emotional|Age: Elderly|Age: Young adult|Age: Middle aged white male|Lives alone|LGBTQ identified"]



******Factors that may decrease risk
[checklist name="variable_1" value="Positive social support|Spirituality|Sense of responsibility to family|Children in the home, pregnancy|Life satisfaction|Reality testing ability|Positive coping skills|Positive problem solving skills|Positive therapeautic relationship"]

Suicide Assessment Outcome:
[text name="variable_1" default=" "]


Trauma History
Have been a victim of abuse or violence [select name="variable_1" value="yes|no|unknown|n/a"]
[checkbox name="variable_1" value="CURRENT|BY HISTORY"]
[checklist name="variable_1" value="Physical Abuse|Sexual Abuse|Verbal Abuse|Psychological Abuse|Religious Abuse|Medical Abuse|Emotional Abuse|Financial Abuse"]


Traumatic event occurred in the past six months [select name="variable_1" value="yes|no|unknown|n/a"]
Current danger[select name="variable_1" value="yes|no|unknown|n/a"]
Direct experience with human-caused assault (kidnapping, mugging, rape, arso, etc?) [select name="variable_1" value="yes|no|unknown|n/a"]
Direct experience with nature-based fear (tornado, earthquake, flood, fire, etc?) [select name="variable_1" value="yes|no|unknown|n/a"]
Have witnessed any frightening events [select name="variable_1" value="yes|no|unknown|n/a"]
What? At what age?:
[textarea name="variable_1" default=" "]

Have close connection to someone who experienced a frightening event [select name="variable_1" value="yes|no|unknown|n/a"]
Have had a frightening spriritual or religious experience [select name="variable_1" value="yes|no|unknown|n/a"]
Have had a frightening spriritual or religious experience [select name="variable_1" value="yes|no|unknown|n/a"]
Notes: [textarea name="variable_1" default=" "]
Range of abusive or traumatic experiences: [textarea name="variable_1" default=" "]
Current symptoms related to trauma: [textarea name="variable_1" default=" "]
Current Triggers: [textarea name="variable_1" default=" "]
Coping resources and strengths: [textarea name="variable_1" default=" "]
Mental Health History
Previous Mental Health History


Previous Outpatient Treatment


Provider Name(s) & Approximate Dates: ??
Intervention/Response: ??
Previous Outpatient Treatment


Psychiatric Hospitalizations


Hospital Name(s) and Approximate Dates: ??


Notes: ??

Suicide Risk Assessment:
Previous Suicide Attempt

When, where, how hospitalized:

******Warning Signs



******Risk Factors




******Factors that may decrease risk


Suicide Assessment Outcome:



Trauma History
Have been a victim of abuse or violence




Traumatic event occurred in the past six months
Current danger
Direct experience with human-caused assault (kidnapping, mugging, rape, arso, etc?)
Direct experience with nature-based fear (tornado, earthquake, flood, fire, etc?)
Have witnessed any frightening events
What? At what age?:


Have close connection to someone who experienced a frightening event
Have had a frightening spriritual or religious experience
Have had a frightening spriritual or religious experience
Notes:
Range of abusive or traumatic experiences:
Current symptoms related to trauma:
Current Triggers:
Coping resources and strengths:

Result - Copy and paste this output:

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