Suicide Risk Assessment Form
Please answer the following questions to assess the risk of suicide.
Full Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Are you currently experiencing emotional distress or depression?
Yes
No
Have you previously been diagnosed with a mental health disorder?
Yes
No
Not sure
Have you ever had thoughts of harming yourself or suicide?
Yes
No
Have you made any previous suicide attempts?
Yes
No
If yes, please provide details of your previous suicide attempts
Do you have a current plan to harm yourself or commit suicide?
Yes
No
Do you have access to lethal means such as firearms, medications, or other dangerous objects?
Yes
No
Are you currently receiving any professional help for your mental health?
Yes
No
Not sure
Is there anything else you would like to share about your mental health or suicidal thoughts?
Submit
Should be Empty: