II. Criteria: Questions 1-4

  1. In the past few weeks, have you wished you were dead?
  2. In the past few weeks, have you felt that your or your family would be better off if you were dead?
  3. In the past week, have you been having thoughts about killing yourself?
  4. Have you ever tried to kill yourself?

III. Criteria: Question 5 (indicated if any positive answer to questions 1-4)

  1. Are you having any thoughts of killing yourself now?

IV. Interpretation

  1. Questions 1-4 negative
    1. No need to ask question 5, and no further evaluation needed
  2. Question 1-4 with at least one positive or patient refuses to answer
    1. Question 5 positive answer (imminent risk)
      1. Complete safety evaluation and mental health evaluation before they can leave a clinical setting
      2. Remove all dangerous items from person and room
    2. Question 5 negative answer (potential risk)
      1. Brief Suicide Risk assessment
      2. Obtain full mental health evaluation if needed based on risk assessment

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