Assessment Context

Reason for assessment:

Routine screening

Triggered by clinical concern

Patient-initiated disclosure

Crisis presentation

Mandatory re-assessment

Lookback timeframe:

C-SSRS Assessment

1. Ideation Level

0 — None 1 — Wish Dead 2 — Nonspecific Thoughts 3 — With Method 4 — With Intent 5 — With Plan

1. Actual Attempt

Self-Injurious Behavior with Intent to Die

2. Interrupted Attempt

3. Aborted/Self-Interrupted Attempt

4. Preparatory Acts or Behaviors

5. Non-Suicidal Self-Injury (NSSI)

Most Recent Behavior

yyyy-mm-dd

Lethality (0-10)

Clinician Risk Override

No Override

Risk Factors

Static / Historical (check all present):

Prior suicide attempt(s)

Family history of suicide

History of trauma / abuse

Chronic pain or illness

Prior psychiatric hospitalization

History of self-harm

Dynamic / Modifiable (check all present):

Active suicidal ideation

Hopelessness

Agitation / Anxiety

Substance use / Intoxication

Recent significant loss

Access to firearms

Access to medication stockpile

Social isolation

Protective Factors

Check all present:

Reasons for living identified

Engaged social support

Active in treatment

Effective coping skills

Future-oriented thinking

Responsibility for children / dependents

Religious / Spiritual engagement

Therapeutic alliance established

Risk Level Determination

Low — No ideation, strong protective factors

Moderate — Ideation without plan, some protective factors

High — Ideation with plan/intent, limited protective factors

Imminent — Active plan, intent, access to means

Risk level rationale:

Means Safety Counseling

Lethal means discussed with patient

Firearms — secured / removed / not applicable

Medication safety reviewed (secured / counted)

Patient agreed to means restriction

Family / support person involved in means restriction

Means safety notes:

Level of Care Decision

Continue outpatient — current frequency

Increase outpatient frequency

Intensive outpatient program (IOP) referral

Partial hospitalization program (PHP) referral

Inpatient psychiatric hospitalization

Emergency department referral

988 Suicide & Crisis Lifeline warm handoff

Crisis Resources Documented

988 Suicide & Crisis Lifeline — call or text 988

Crisis Text Line — text HOME to 741741

Local crisis team / emergency contact:

Diagnosis

Diagnosis Search

Associated diagnosis

Coding Details

Status

Select status...

Severity

Select severity...

Onset Date

YYYY-MM-DD

Resolved Date

YYYY-MM-DD

Follow-Up

Follow-up interval:

24 hours

48 hours

72 hours

1 week

Next scheduled session

Responsible party:

Consultation / Collateral notes:

Plan and Follow-Up

Plan area	Details
Next visit
Orders & referrals
Patient instructions
Monitoring & safety

Assessment Context

C-SSRS Assessment

C-SSRS

Suicidal Ideation Severity ⓘ

Suicidal behavior (lifetime; most recent date below)

Risk Details

Counseling - C-SSRS Suicide Risk Assessment

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