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Suicide & Self-Harm Safety Screen
SUICIDE, SELF-HARM & SAFETY SCREEN
Current thoughts of suicide?
No
Yes
thoughts of self-harm?
No
Yes
Plan?
No
Yes
Intent?
No
Yes
Access to means?
No
Yes
Past suicide attempt/self-harm
No
Yes
Details
Current homicidal/violent thoughts?
No
Yes
Protective factors/supports
Safety concerns identified
Provider risk assessment / disposition / safety plan
Emergency action if indicated
Patient signature (when appropriate)
Date
Provider signature
Date
Submit
