Suicidal Behaviors Screening Questionnaire Form
Please answer each question honestly. This form is for screening purposes only and does not collect sensitive personal identifiers.
In the past month, how often have you had thoughts about ending your life?
*
Never
Rarely
Sometimes
Often
Very Often
Have you ever made a plan to end your life?
*
Yes
No
Have you ever attempted to end your life?
*
Yes
No
How would you rate your current level of hopelessness?
*
1
2
3
4
5
Do you have access to means that could be used to harm yourself?
*
Yes
No
Prefer not to say
Who can you talk to if you feel overwhelmed?
*
Have you sought help or support for your thoughts or feelings?
*
Yes
No
Not sure
Which of the following best describes your support system?
*
Family
Friends
Mental health professional
Community resources
No support system
Other
If you have ever attempted to end your life, how many times have you attempted?
*
What is one thing that gives you hope or helps you cope during difficult times?
*
Would you like to share anything else related to your thoughts or feelings?
Submit
Should be Empty: