Templates › Forms › SEO page

Run: Inmate Medical and Suicide Risk Screening Form

Screen inmates for urgent medical needs, current medications, and suicide risk in one intake form. Use it to trigger observation, referral, and documentation...

Fill this out, get a PDF emailed to you. No account required. Want to run it with your team and track results? Sign up free →

Intake and Screening Consent

Screening date (required)

Screening time (required)

Screened by (required)

Inmate ID (required)

Consent and disclosure acknowledgement (required)

Yes No N/A

Anonymous submission

Use only if your facility allows anonymous safety reporting. For intake screening, this should typically remain unchecked because the screening must be linked to the correct person.

Yes No N/A

Immediate Medical Concerns

Is the person experiencing a current medical emergency? (required)

Describe the emergency (required)

Hospitalization or emergency care in the last 30 days? (required)

Provide details

Mobility, sensory, or disability-related accommodation needs

Select any needs that may affect safe housing, observation, or access to care.

Current Medications and Health Conditions

Is the person currently taking any medications? (required)

List current medications (required)

Known chronic medical conditions

Describe other condition

Known allergies or adverse reactions

Suicide Risk Screening

Are you having thoughts of hurting yourself or ending your life right now? (required)

Any suicidal thoughts in the past 30 days? (required)

History of suicide attempt or self-harm? (required)

Describe history of attempt or self-harm

Current plan, intent, or access to means? (required)

Protective factors or reasons for living

Observation, Referral, and Final Disposition

Assigned risk level (required)

Observation placement required? (required)

Observation type (required)

Referral or follow-up actions

Final notes

Get your results

Enter your email — we'll send you a PDF of your filled-out template, plus the occasional MangoScoop newsletter (templates, workflow tips, product updates). Unsubscribe anytime — link is in every email.

Email (required)

Your name (optional)

Generated with MangoApps Templates — browse 250+ free