Safe-T Assessment - Friends for Lives

Support Tutor Name

Form Completion Date:

Life Student Name

Phone

Email

Address

First Ask the Quick Risk Assessment Question Below...

"Have they actually done anything, started to do anything, or prepared to do anything to end their own life?”

No = Low Risk

Yes = Moderate Risk

Yes (Within Last three months) = High Risk

See Assessmet Calculation Chart & Triage Guidlines Below...

none

Risk Factors...

Access to and contemplation of lethal methods:

Yes

No

If access and contemplation has been established then provide further details and discuss romoval of and/or isolation from access:...

Psychiatric Profile:

Presenting Symptoms

Anhedonia

Impulsivity

Hopelessness or despair

Masking

Anxiety and/or panic

Insomnia

Command hallucinations

Psychosis

None

Family History

Suicide

Suicidal behavior

Psychiatric diagnoses requiring hospitalization

None

Precipitants/Stressors

Change in Treatment

New Diagnosis

Recent inpatient discharge

Change in provider or treatment (i.e., medications, psychotherapy, milieu)

Hopeless or dissatisfied with provider or treatment

Non-compliant or not receiving treatment

None

Protective Factors...

Internal

Ability to cope with stress

Frustration tolerance

Religious beliefs

Fear of death or the actual act of killing self

Identifies reasons for living

None

External

Cultural, spiritual and/or moral attitudes against suicide

Responsibility to children

Beloved pets

Supportive social network of family or friends

Positive therapeutic relationships

Engaged in work or school

None

Ideation Severity and Behaviour/Lethality Assessment:

FREQUENCY: How many times have they had these thoughts?

(1) Less than once a week

(2) Once a week

(3) 2-5 times in week

(4) Daily or almost daily

(5) Many times each day

(0) N/A

DURATION: When they have the thoughts how long do they last?

(1) Fleeting - few seconds or minutes

(2) Less than 1 hour/some of the time

(3) 1-4 hours/a lot of time

(4) 4-8 hours/most of day

(5) More than 8 hours/persistent or continuous

(0) N/A

CONTROLLABILITY: Could/can they stop thinking about killing themself or wanting to die if they want to?

(1) Easily able to control thoughts

(2) Can control thoughts with little difficulty

(3) Can control thoughts with some difficulty

(4) Can control thoughts with a lot of difficulty

(5) More than 8 hours/persistent or continuous

(0) N/A

DETERRENTS: Are there things - anyone or anything (e.g., family, religion, pain of death) - that stopped them from wanting to die or acting on thoughts of suicide?

(1) Deterrents definitely stopped you from attempting suicide

(2) Deterrents probably stopped you

(3) Uncertain that deterrents stopped you

(4) Deterrents most likely did not stop you

(5) Deterrents definitely did not stop you

(0) N/A

REASONS FOR IDEATION: What sort of reasons did they have for thinking about wanting to die or killing themself? Was it to end the pain or stop the way they were feeling (in other words they couldn’t go on living with this pain or how they were feeling) or was it to get attention, revenge or a reaction from others? Or both?

(1) Completely to get attention, revenge or a reaction from others

(2) Mostly to get attention, revenge or a reaction from others

(3) Equally to get attention, revenge or a reaction from others and to end/stop the pain

(4) Mostly to end or stop the pain (you couldn’t go on living with the pain or how you were feeling)

(5) Completely to end or stop the pain (you couldn’t go on living with the pain or how you were feeling)

(0) N/A

TOTAL SCORES ABOVE AND DEVIDE BY 5 TO CALCULATE A SUICIDE RISK LEVEL ASSESSMENT:

1 or 2 = Low Suicide Risk. 3 = Moderate Suicide Risk. 4 or 5 = High Suicide Risk...

Assessed Suicide Risk

Based on all of the information collected on this form, please give your overall assessment of the level of suicide risk.

Very High

High

Moderate to High

Moderate

Low to Moderate

Low

Very Low

N/A

Reccomended Triage Action

Using the Triage Guidlines Chart, Select the Triage Action Level required for this Life Student.

Red

Orange

Yellow

Action Taken and Planned Report

Give details of the how a support plan was actioned for this Life Student and what are the next step recommendations.

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