Suicide Watch Initial Assessment -Clinician
Precision Psychiatric Services
Patient Name
DOB
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Safety Cell Location
Bob Wiley
Pretrial
South County
JDF
Date and Time of Evaluation
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Type of Watch
Constant
q15 min staggered
Other
Reason for Watch
SI or threat of self harm
High risk for self harm or suicide attempt
Active Plan for self harm or suicide
Other
Current Status:
Medication Compliant?
Yes
No
Intermittently
Other
Current SI?
Yes
No
Intermittent
Other
Current HI?
Yes
No
Intermittent
Other
Recent Self Harm?
Yes
No
Unknown
Other
Interventions During Session:
Mental Status Exam
Appearance:
Appropriate
Meticulous
Unclean
Disheveled
Other
Speech:
Appropriate
Expressive
Loud
Slowed
Pressured
Slurred
Other
Mood:
Appropriate
Depressed
Euphoric
Anxious
Angry
Irritable
Other
Affect:
Appropriate
Tearful
Blunted
Flat
Labile
Hostile
Other
Thought Process:
Coherent
Circumstantial
Tangential
Loose Associations
Poverty of Thought
Flight of Ideas
Other
Thought Content:
Appropriate
Auditory Halucinations
Visual Hallucinations
Obsessive
Delusional
Suicidal Ideations
Homicidal Ideations
Other
Orientation:
Person
Place
Time
Situation
Intelligence:
above average
average
below average
well below average
Memory:
Intact
Immediate impaired
Recent impaired
Remote impaired
Insight:
Good
Fair
Poor
Judgement:
Good
Fair
Poor
Behavior:
Appropriate
Belligerent
Agitated
Impulsive
Withdrawn
Other
Columbia Suicide Severity Rating Scale
1) Have you wished you were dead or wished you could go to sleep and not wake up?
Yes
No
2) Have you actually had any thoughts of killing yourself?
Yes
No
3) Have you been thinking about how you might do this?
Yes
No
E.g.
“I thought about taking an overdose but I never made a specific plan as to when
where or how I would actually do it....and I would never go through with it.”
4) Have you had these thoughts and had some intention of acting on them?
Yes
No
As opposed to
“I have the thoughts but I definitely will not do anything about them.”
5) Have you started to work out or worked out the details of how to kill yourself?Do you intend to carry out this plan?
Yes
No
6) Have you ever done anything, started to do anything, or prepared to do anything to end your life?
Yes
No
Examples: Collected pills, obtained a gun, gave away valuables, wrote a will or suicide note, took out pills but didn’t swallow any, held a gun but changed your mind or it was grabbed from your hand, went to the roof but didn’t jump; or actually took pills, tried to shoot you rself, cut yourself, tried to hang yourself, etc.
Was this within the past three months?
Yes
No
Treatment Goals:
Patient will not engage in self-harming/self-injurious behaviors
Patient will describe and demonstrate at least two (2) additional coping skills, specify
Patient will tell staff if he/she experiences suicidal ideatiojns/plan
Patient will take medication as prescribed by the psychiatric provider
Patient will work with MHP to develop collaborative safety plan including identifying maladaptive coping mechanisms and replacing with healthy coping plans
Patient will work on assignments, specify:
Patient will discuss protective factors and reasons for living
Other
Risk Factors:
Intoxicated or detoxing from alcohol/drugs (CIWA/COWS)
Terminal/incurable medical illness or pain
Refused Intake
Placement in segregation/isolation
Non-adherence to psychotropic medication
Reports of giving items away
Bad news (legal, loss of loved one, visit cancelled/no show, privileges revoked, serious stress, recent rejection or loss)
Suicide note found
Prior suicide watch placement in jail
High profile crime (media attention)
Prior suicide attempts
Serious charges
Active major depression/ mania/ hallucinations/ delusions
Current charges involve crime against child
First incarceration or arrest
Recent release from psychiatric hospital
Hopelessness, feelings of guilt/ burden/worthlessness, flashbacks, severe anxiety, agitation, overwhelmed
Age (adolescent, elderly)
Male gender
Transgender
Impulsive
Military veteran
Heightened preoccupation with legal issues (new charges/sentencing, lengthy sentence, denied parole/probation, pending release after long incarceration)
Childhood history of trauma/abuse
Family history of suicide attempts
Anniversary/Anniversary of important loss
History of violence and/or domestic abuse
Humiliatingly events/rejection (sexual assault)
Non-suicidal self-injury
Protective Factors
Identifies reason for living and engages in CSP
Spouse/family support
Friend/social support
Children at home
Has insight into problems/issues
Fear of death or dying due to pain and suffering
Responsibility to family or others; living with family
Belief that suicide is immoral, high spirituality
Engaged in mental health treatment
Had defined future goals/plans
Enrolled in treatment
Other
Plan
Discharge from watch, follow up in accordance with policy or sooner as clinically indicated
Continue current SW and follow up daily
Estimated Acute Self Harm Suicide Risk Level
Low
Intermediate
High
Referred to
Medical
Psychiatric Provider
Discharge planner
Other
Should be seen by psychiatry within ( ) days:
Follow up by clinician needed in:
24 hours
12 hours
Other
Signature
Provider Name:
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