C-SSRS Suicide Screen

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Patient First Name

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Patient Last Name

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Please select the appropriate answers

Since Last Contact. Please answer questions 1 and 2.

1) Have you wished you were dead or wished you could go to sleep and not wake up?

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2- Have you actually had any thoughts of killing yourself?

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If YES, answer all questions 3, 4, 5, and 6. If NO, skip directly to question 6.

3) Have you thought about how you might do this? (For example, “I thought about taking an overdose but I never worked out the details about when, where, and how I would do that and I would never act on these thoughts.”)

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4) Have you had any intention of acting on these thoughts of killing yourself, as opposed to you have the thoughts, but you definitely would not act on them? (For example, “I had the thought of killing myself by taking an overdose and am not sure whether I would do it or not.”)

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5) Have you done anything, started to do anything, or prepared to do anything to end your life? (For example: Collected pills, obtained a gun, gave away valuables, wrote a will or suicide note, took out pills but didn’t swallow any, held a gun but changed your mind about hurting yourself or it was grabbed from your hand, went to the roof to jump but didn’t; or actually took pills, tried to shoot yourself, cut yourself, tried to hang yourself, etc.)

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If YES, what did you do?

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6) Have you done anything, started to do anything, or prepared to do anything to end your life? (For example: Collected pills, obtained a gun, gave away valuables, wrote a will or suicide note, took out pills but didn’t swallow any, held a gun but changed your mind about hurting yourself or it was grabbed from your hand, went to the roof to jump but didn’t; or actually took pills, tried to shoot yourself, cut yourself, tried to hang yourself, etc.)

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If YES, what did you do?

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Signature:

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Printed Name:

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Date:

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