SOP_NUMBER: 508.29-att-1 TITLE: Suicide Risk Assessment Instrument DIVISION: Mental Health TOPIC_AREA: 508 Policy - Mental Health Suicide Prevention/ACU/CSU/BTU EFFECTIVE_DATE: 2020-07-01 WORD_COUNT: 997 POWERDMS_URL: https://public.powerdms.com/GADOC/documents/407571 URL: https://gps.press/sop-data/508.29-att-1/ SUMMARY: This form is used to assess suicide risk in incarcerated individuals at two points: during initial assessment and upon discharge from suicide precautions. Mental health providers use this instrument to evaluate suicidal behaviors, risk factors, and protective factors, then determine the appropriate risk level (mild or suicide precautions) and corresponding interventions. The assessment guides decisions about placement on suicide watch, counseling frequency, and safety precautions. KEY_TOPICS: suicide risk assessment, suicide precautions, suicidal ideation, self-harm, SIB, suicide attempt history, risk factors, protective factors, mental health screening, suicide prevention, ACU placement, CSU placement, incarcerated individuals, mental health assessment, suicide watch ATTACHMENTS: 1. Suicide Risk Assessment Instrument URL: https://gps.press/sop-data/508.29-att-1/ 2. Suicide Precautions Treatment Plan URL: https://gps.press/sop-data/508.29-att-2/ 3. Suicide Precautions Rounds URL: https://gps.press/sop-data/508.29-att-3/ 4. Suicide Precautions Log URL: https://gps.press/sop-data/508.29-att-4/ ======================================================================== FULL TEXT: ======================================================================== 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.