II. Criteria: Questions 1-4
- In the past few weeks, have you wished you were dead?
- In the past few weeks, have you felt that your or your family would be better off if you were dead?
- In the past week, have you been having thoughts about killing yourself?
- Have you ever tried to kill yourself?
III. Criteria: Question 5 (indicated if any positive answer to questions 1-4)
- Are you having any thoughts of killing yourself now?
IV. Interpretation
- Questions 1-4 negative
- No need to ask question 5, and no further evaluation needed
- Question 1-4 with at least one positive or patient refuses to answer
- Question 5 positive answer (imminent risk)
- Complete safety evaluation and mental health evaluation before they can leave a clinical setting
- Remove all dangerous items from person and room
- Question 5 negative answer (potential risk)
- Brief Suicide Risk assessment
- Obtain full mental health evaluation if needed based on risk assessment
- Question 5 positive answer (imminent risk)