SOP 508.29-att-1: Suicide Risk Assessment Instrument

SOP 508.29
Attachment 1

7/1/20

Offender’s Name: _________________________ GDC ID#___________________

# SUICIDE RISK ASSESSMENT INSTRUMENT

(complete twice, 1) at initial assessment and 2) at discharge from Suicide Precautions)

Reason for Referral:
___1) Assess need for Suicide Precautions/baseline assessment
___2) Assessment for discharge from Suicide Precautions status (required)

History of Suicidal Behavior

[ ] Previous suicide attempt(s) in free world
Note when and method: ________________________________________
____________________________________________________________
[ ] Previous suicide attempt(s) in confinement
Note when and method: ________________________________________
____________________________________________________________
[ ] Serious suicide attempt(s) or SIB within past year
Note when and method: ________________________________________
____________________________________________________________

RISK FACTORS (Check all that apply)
___Resolved Plans and Preparation

[ ] Fearlessness of physical pain/injury/death

[ ] Availability of means and opportunity

[ ] Specificity of plan

[ ] Preparations for attempt

[ ] Significant intensity and duration of suicidal ideation

___ Suicidal Desire and Ideation

[ ] Can identify no reason for living

[ ] Wish to die

[ ] Talk of death and/or suicide

[ ] Perceives self as burden to others

[ ] Passive attempt, e.g. stops eating/taking fluids

___Current and Recent (within past 6 months) Stressors

[ ] Anniversary of important loss: (specify)______________________________

[ ] Recent/anticipated rejection/loss/bad news: (specify)____________________

[ ] Isolation/segregation placement

[ ] Stressful dorm environment with concerns for safety

[ ] Recent physical/sexual abuse in prison

[ ] Recent negative court hearing outcome

[ ] Anticipated long-term lock-down

[ ] First incarceration

[ ] Known future court proceeding with potential for lengthened sentence

[ ] Chronic, serious or terminal illness

[ ] Limited/lack of support system

[ ] Other: ________________________________________________________

Form no. M69-01-01 Page 1 of 4

Retention Schedule: Completed forms shall be placed in the offender’s mental health file (section 4). At the end of the offender’s need
for mental health services and/or sentence, the mental health file shall be placed within the offender’s health record and retained for 10
years.

SOP 508.29
Attachment 1

7/1/20

Offender’s Name: _________________________ GDC ID# ___________________

___ General Symptomatic Presentation

[ ] Initial, recurrent, or exacerbation of clinical disorder

[ ] Feels lonely and alienated

[ ] Feels hopeless/helpless

[ ] No plans for the future

[ ] Depressed mood

[ ] Insomnia

[ ] Nightmares

[ ] Anxious/agitated

[ ] Poor problem-solving/poor judgment

[ ] Fearful for safety

[ ] Unbearable distress

[ ] Diagnosed personality disorder

[ ] Command hallucinations/delusions associated with SIB

[ ] Poor compliance with treatment or medication

[ ] Other: _________________________________________________________
___Other Predispositions to Suicidal Behavior

[ ] Chaotic family history

[ ] Family history of suicide

[ ] History of physical and/or sexual abuse

[ ] Other: _________________________________________________________
___Impulsivity

[ ] Significant current impulsive/violent behavior (physical/verbal aggression)

___Additional Factors/Considerations : ______________________________________
__________________________________________________________________
__________________________________________________________________

PROTECTIVE FACTORS

[ ] Support from family and/or significant others (ongoing, frequent contact)

[ ] Role in caring for children

[ ] Strong religious support and beliefs

[ ] Sense of belonging

[ ] Decreased state of anxiety or distress

[ ] Future life plans

[ ] Has a legal trade

[ ] Healthy stress management (e.g. exercise, reading, drawing, meditation)

[ ] Improved cell/dorm placement

[ ] Other: _______________________________________________________________

____________________________________________________Date: _______________
Signature of MH provider completing pages 1 & 2 if other than Psychologist/Psychiatrist/APRN

Form M69-01-01 Page 2 of 4

Retention Schedule: Completed forms shall be placed in the offender’s mental health file (section 4). At the end of the offender’s need
for mental health services and/or sentence, the mental health file shall be placed within the offender’s health record and retained for 10
years.

SOP 508.29
Attachment 1

7/1/20

Offender’s Name: _________________________ GDC ID# ___________________

RISK LEVEL AND INTERVENTION GUIDELINES

Always use in conjunction with clinical judgment.

Mild:
____Non-multiple attempter with ideation of limited intensity/duration, no or mild symptoms of

resolved plans and preparation factor, and no/few risk factors.

Recommended Interventions: Coach offender on coping strategies, seeking social support, and best way
to access MH staff if symptoms worsen. Establish appropriate interval for follow-up.

Suicide Precautions:
____Multiple attempter with any significant finding and/or general symptomotology.
____Non-multiple attempter with any notable findings or moderate-to-severe
symptoms of the Resolved Plans and Preparations factor (see pg 1).
____Non-multiple attempter requiring significant medical intervention
____Other Justification: _____________________________________________________

Recommended Interventions: Placement on Suicide Precautions is mandatory. Increase
frequency and/or duration of counseling contacts to address identified stressors and facilitate
symptom resolution. Consider referral to Suicide Prevention group. Enhance protective factors.
Frequently re-evaluate suicidal risk factors. Consider consultation. Consider medication if not
already on it. Carefully document clinical decisions and activities and inform appropriate on-call
staff as needed. Determine precautionary measures/restrictions. Provide frequent assessment by a
mental health counselor and/or an upper-level provider to determine need for ACU/CSU
placement. IF PLACED IN ACU/CSU, COMPLETE THE SUICIDE PRECAUTIONS ROUNDS
FORM (Attachment 3 - M69-01-03)

Indicate additional interventions below:

[ ] Medication referral/evaluation

[ ] Increase therapeutic contacts to recommended frequency of ___ time(s) per________

[ ] Initiate/Continue Suicide Precautions placement (recommend to security)

[ ] 15-minute checks [ ] Constant watch [ ] One-on-one [ ] Other

[ ] Jump-suit [ ] Paper gown [ ] Suicide proof gown [ ] Booties

[ ] Normal meals with utensils [ ] Finger foods

[ ] No personal property [ ] Allowed property:__

Psychologist/Psychiatrist/APRN signature: ____________________________________

Printed name: _____________________________________Date: __________________

Form M69-01-01 Page 3 of 4

Retention Schedule: Completed forms shall be placed in the offender’s mental health file (section 4). At the end of the offender’s need
for mental health services and/or sentence, the mental health file shall be placed within the offender’s health record and retained for 10
years.

SOP 508.29
Attachment 1

7/1/20

Offender’s Name: _________________________ GDC ID# ___________________

Offender was placed on Suicide Precautions on _________ (date) for the following
reasons:
_______________________________________________________________

Improvement noted in the following clinical areas:

[ ] Reduced/eliminated suicidal ideation [ ] Decreased fearfulness

[ ] No current suicidal intent/plans [ ] Absence of acute psychotic symptoms

[ ] No current SIB [ ] Improved sleep

[ ] Decreased depression [ ] Future orientation

[ ] Decreased anxiety [ ] Cooperation with treatment

[ ] Decreased agitation [ ] Resolution of situational stressors

[ ] Other:__________________________

Additions/improvements in other protective factors: ____________________________________
_________________________________________________________________________________

Remaining issues to be addressed: _______________________________________________

__________________________________________________________________________

                               ___

RECOMMENDATIONS

[for current Suicidal Precautions status, change, or discharge from Suicide Precautions]

[ ] No special interventions or placement needed at this time.

[ ] Medication referral/evaluation

[ ] Increase therapeutic contacts to recommended frequency of ___ time(s) per_______

[ ] Other: ______________________________________________________________

[ ] Discharge from Suicide Precaution Status
Follow-up recommendations: __________________________________________
__________________________________________________________________

Psychologist/Psychiatrist/APRN signature: ____________________________________
Printed name: _____________________________________Date: _________________

This instrument adapted from the work of Joiner Jr. T., Walker, R., Rudd, M., Jobes, D. (1999). Scientizing and
routinizing the assessment of suicidality in outpatient practice. Professional Psychology: Research and Practice, 30,
447-452.

Form M69-01-01 Page 4 of 4

Retention Schedule: Completed forms shall be placed in the offender’s mental health file (section 4). At the end of the offender’s need
for mental health services and/or sentence, the mental health file shall be placed within the offender’s health record and retained for 10
years.