SUICIDAL BEHAVIOR
(Check all that apply, so long as these are separate events; must ask about all types)
Actual Attempt:
A potentially self-injurious act committed with at least some wish to die, as a result of act. Behavior was in part thought of as method to kill oneself. Intent
does not have to be 100%. If there is any intent/desire to die associated with the act, then it can be considered an actual suicide attempt. There does not
have to be any injury or harm, just the potential for injury or harm. If person pulls trigger while gun is in mouth but gun is broken so no injury results,
this is considered an attempt.
Inferring Intent: Even if an individual denies intent/wish to die, it may be inferred clinically from the behavior or circumstances. For example, a highly lethal
act that is clearly not an accident so no other intent but suicide can be inferred (e.g., gunshot to head, jumping from window of a high floor/story). Also, if
someone denies intent to die, but they thought that what they did could be lethal, intent may be inferred.
Did you do anything to try to kill yourself or make yourself not alive anymore? What did you do?
Did you hurt yourself on purpose? Why did you do that?
Did you______ as a way to end your life?
Did you want to die (even a little) when you_____?
Were you trying to make yourself not alive anymore when you _____?
Or did you think it was possible you could have died from_____?
Or did you do it purely for other reasons, not at all to end your life or kill yourself (like to make yourself feel better, or get
something else to happen)? (Self-Injurious Behavior without suicidal intent)
If yes, describe:
Has subject engaged in Non-Suicidal Self-Injurious Behavior?
Has subject engaged in Self-Injurious Behavior, intent unknown?
Yes No
□ □
Total # of
Attempts
______
Yes No
□ □
Yes No
□ □
Interrupted Attempt:
When the person is interrupted (by an outside circumstance) from starting the potentially self-injurious act (if not for that, actual attempt would have
occurred).
Overdose: Person has pills in hand but is stopped from ingesting. Once they ingest any pills, this becomes an attempt rather than an interrupted attempt.
Shooting: Person has gun pointed toward self, gun is taken away by someone else, or is somehow prevented from pulling trigger. Once they pull the trigger,
even if the gun fails to fire, it is an attempt. Jumping: Person is poised to jump, is grabbed and taken down from ledge. Hanging: Person has noose around neck
but has not yet started to hang - is stopped from doing so.
Has there been a time when you started to do something to make yourself not alive anymore (end your life or kill yourself) but
someone or something stopped you before you actually did anything? What did you do?
If yes, describe:
Yes No
□ □
Total # of
interrupted
______
Aborted Attempt or Self-Interrupted Attempt:
When person begins to take steps toward making a suicide attempt, but stops themselves before they actually have engaged in any self-destructive behavior.
Examples are similar to interrupted attempts, except that the individual stops him/herself, instead of being stopped by something else.
Has there been a time when you started to do something to make yourself not alive anymore (end your life or kill yourself) but you
changed your mind (stopped yourself) before you actually did anything? What did you do?
If yes, describe:
Yes No
□ □
Total # of
aborted
or self-
interrupted
______
Preparatory Acts or Behavior:
Acts or preparation towards imminently making a suicide attempt. This can include anything beyond a verbalization or thought, such as assembling a specific
method (e.g., buying pills, purchasing a gun) or preparing for one’s death by suicide (e.g., giving things away, writing a suicide note).
Have you done anything to get ready to make yourself not alive anymore (to end your life or kill yourself)- like giving things away,
writing a goodbye note, getting things you need to kill yourself?
If yes, describe:
Yes No
□ □
Total # of
preparatory
acts
______
Suicide:
Death by suicide occurred since last assessment.
Most Lethal
Attempt
Date:
Actual Lethality/Medical Damage:
0. No physical damage or very minor physical damage (e.g., surface scratches).
1. Minor physical damage (e.g., lethargic speech; first-degree burns; mild bleeding; sprains).
2. Moderate physical damage; medical attention needed (e.g., conscious but sleepy, somewhat responsive; second-degree burns; bleeding of major vessel).
3. Moderately severe physical damage; medical hospitalization and likely intensive care required (e.g., comatose with reflexes intact; third-degree burns less
than 20% of body; extensive blood loss but can recover; major fractures).
4. Severe physical damage; medical hospitalization with intensive care required (e.g., comatose without reflexes; third-degree burns over 20% of body;
extensive blood loss with unstable vital signs; major damage to a vital area).
5. Death
Potential Lethality: Only Answer if Actual Lethality=0
Likely lethality of actual attempt if no medical damage (the following examples, while having no actual medical damage, had potential for very serious
lethality: put gun in mouth and pulled the trigger but gun fails to fire so no medical damage; laying on train tracks with oncoming train but pulled away before
run over).
0 = Behavior not likely to result in injury
1 = Behavior likely to result in injury but not likely to cause death
2 = Behavior likely to result in death despite available medical care
©"2008"Research"Foundation"for"Mental"Hygiene,"Inc." " """"""""C>SSRS—Pediatric – Since Last Visit - Clinical"(Version"6/23/10)"""" " """"""""""""""""""""""""Page"2"of"2"