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Ask questions 1 and 2
1. Have you wished you were dead or wished you could go to sleep and not wake up?
2. Have you actually had any thoughts of killing yourself?
If YES to 2, ask questions 3, 4. 5. and 6. If NO to 2, go directly to question 6.
3. Have you been thinking about how you might do this?
4. Have you had these thoughts and had some intention on acting on them?
5. Have you started to work out or worked out the details of how to kill yourself? Do you intend to carry out this plan?
6. Have you ever done anything, started to do anything, or prepared to anything to end your life?
If Yes, was this in the past 3 months?
Risk Interpretation:
• • •

C-SSRS Medical Form

Counselor Professional

There are 3 copies in use.
Published: Jan. 17, 2022, 8:18 p.m.
Doctor: Dr. History Physical
Rating: 0   /

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