Suicide Risk Assessment and Crisis Response Plan

Steps

This section matters because it turns a high-risk conversation into a repeatable sequence with clear ownership, verification, and escalation points.

• Establish a private, safe interview environment

  The clinician confirms that the interview space is private, free from interruption, and that no third parties are present without the client’s consent. For telehealth sessions, the clinician verifies the client’s physical address and confirms the client is alone or in a safe location before proceeding.

  • Remove or secure any sharps, cords, or ligature points visible in the immediate clinical environment per facility environmental safety policy.
  • Confirm the session is being documented in the EHR under the correct client record.
  • Inform the client of the limits of confidentiality, including duty-to-warn and mandatory reporting obligations, using plain language.
• Administer the Columbia Suicide Severity Rating Scale (C-SSRS) screening

  The clinician administers the C-SSRS Screener (or Lifetime/Recent version for initial assessments) using the standardized script verbatim to ensure instrument validity.

  Ideation items to assess (C-SSRS Ideation Intensity Scale):

  1. Wish to be dead
  2. Non-specific active suicidal thoughts
  3. Active ideation with method (no plan or intent)
  4. Active ideation with some intent to act, without specific plan
  5. Active ideation with specific plan and intent

  Behavior items to assess:

  • Preparatory acts or behaviors
  • Aborted, interrupted, or actual suicide attempts (lifetime and recent)
  • Non-suicidal self-injurious behavior (document separately)

  Record the highest ideation category endorsed and the most recent date of any behavior. Enter all C-SSRS scores in the EHR clinical note.

• Conduct structured clinical interview to identify risk factors

  The clinician explores and documents the following risk factor domains using open-ended clinical interview, supplementing C-SSRS data:

  Static (historical) risk factors:

  • Prior suicide attempts (number, lethality, medical severity)
  • Family history of suicide or attempt
  • History of trauma, abuse, or adverse childhood experiences
  • Chronic medical illness or pain

  Dynamic (modifiable) risk factors:

  • Current psychiatric diagnosis (depression, bipolar, psychosis, SUD, PTSD)
  • Current substance use or intoxication
  • Recent significant loss (relationship, employment, housing, bereavement)
  • Access to lethal means (firearms, medications, other)
  • Social isolation or lack of support
  • Recent discharge from inpatient psychiatric care (within 90 days)
  • Hopelessness (administer Beck Hopelessness Scale if indicated)
  • Agitation, insomnia, or recent impulsive behavior

  Document each identified risk factor explicitly in the clinical note. Do not use generic language such as ‘multiple risk factors present.’

• Identify and document protective factors

  The clinician explores and documents protective factors that reduce suicide risk and will anchor the safety plan:

  Internal protective factors:

  • Reasons for living (children, pets, faith, future goals)
  • Problem-solving ability and coping skills
  • Fear of death or pain
  • Sense of responsibility to others

  External protective factors:

  • Strong social support network (name specific individuals)
  • Engaged in ongoing mental health treatment
  • Religious or cultural beliefs that discourage suicide
  • Employment, housing stability, or structured daily routine
  • Absence of or restricted access to lethal means

  Document each protective factor by name. Protective factors identified here will be directly incorporated into Steps 5 and 6 of the Stanley-Brown Safety Plan.

• Determine overall risk stratification level

  The clinician synthesizes C-SSRS scores, risk factors, and protective factors to assign a clinical risk stratification level using the facility’s approved risk decision guide. Risk level must be explicitly documented — do not use vague language such as ‘some risk present.’

  Risk Level	Typical Indicators	Default Disposition
  Low	Passive ideation only; no plan/intent; strong protective factors; no prior attempts	Outpatient safety plan; schedule follow-up within 7 days
  Moderate	Active ideation without plan/intent; some risk factors; moderate protective factors	Intensive outpatient or crisis stabilization; safety plan; means restriction counseling
  High	Active ideation with plan or intent; prior attempt; limited protective factors	Urgent psychiatric evaluation; consider voluntary hospitalization
  Imminent	Active plan, intent, and means; current intoxication; preparatory behaviors	Initiate involuntary hold (e.g., 5150/Baker Act) or call 911; do not leave client alone

  The supervising clinician or on-call psychiatrist must co-sign the risk stratification for High and Imminent levels before the client is discharged from the encounter.

• Collaboratively build the Stanley-Brown Safety Planning Intervention (SPI)

  The clinician completes the six-step Stanley-Brown Safety Planning Intervention collaboratively with the client. Each step must be personalized — generic or pre-filled plans are not acceptable per SPI best practices.

  SPI Step 1 — Warning signs: The clinician asks the client to identify personal warning signs (thoughts, images, moods, behaviors) that a crisis may be developing. Document 2–4 specific, individualized warning signs.

  SPI Step 2 — Internal coping strategies: The clinician and client identify activities the client can do alone to distract from suicidal thoughts (e.g., ‘go for a 20-minute walk,’ ‘listen to a specific playlist’). Document 2–3 specific strategies.

  SPI Step 3 — Social contacts and settings that provide distraction: The clinician and client identify people and places that provide positive distraction (not necessarily disclosing the crisis). Document names and contact numbers.

  SPI Step 4 — People to ask for help: The clinician and client identify trusted individuals the client can contact directly during a crisis. Document full names and phone numbers. Confirm the client has these numbers saved in their phone before leaving.

  SPI Step 5 — Professional and agency contacts: Document the client’s treating clinician, after-hours crisis line, 988 Suicide and Crisis Lifeline, local mobile crisis team, and nearest emergency department. Include direct phone numbers — not just agency names.

  SPI Step 6 — Means restriction: See Step 7 of this SOP for the full means restriction counseling procedure.

  The clinician provides the client with a signed copy of the completed SPI and retains a copy in the EHR.

• Conduct means restriction counseling

  The clinician conducts means restriction counseling as a core component of the safety plan, consistent with evidence-based lethal means counseling (LMC) protocols.

  Firearms:

  • The clinician directly asks whether the client owns or has access to firearms.
  • If yes: collaboratively identify a trusted third party (family member, friend) who can temporarily store the firearm outside the home, or discuss use of a gun safe with a combination unknown to the client.
  • Document the agreed-upon storage plan by name of responsible party and method.
  • Provide the means restriction counseling handout.

  Medications:

  • The clinician reviews current prescriptions and OTC medications.
  • Recommend dispensing medications in limited quantities (e.g., 1-week supply) during elevated risk periods.
  • Recommend a trusted person hold and dispense medications if indicated.
  • Coordinate with prescribing provider to adjust prescription quantities.

  Other means (bridges, heights, sharp objects, toxic substances):

  • The clinician asks about any other means the client has considered and documents the response.
  • Collaboratively identify barriers or removal strategies for any identified means.

  Document the specific means discussed, the client’s stated willingness to restrict access, and the agreed-upon restriction plan. If the client refuses means restriction, document the refusal and escalate risk level.

• Verify crisis contacts are accessible and functional

  The clinician verifies that all crisis contacts listed in SPI Step 5 are accurate, reachable, and saved in the client’s phone before the session ends.

  Verification checklist:

  • 988 Suicide and Crisis Lifeline number confirmed (call or text 988)
  • Local mobile crisis team phone number confirmed and current
  • Treating clinician’s after-hours contact number confirmed
  • Nearest emergency department address confirmed
  • At least two personal support contacts (SPI Step 4) have confirmed phone numbers saved in client’s device
  • Client can verbally state the first step they will take if warning signs appear

  If the client does not have a phone or reliable access to contacts, document the barrier and identify an alternative access plan (e.g., neighbor, community center, crisis walk-in location).

• Document the clinical encounter and complete risk assessment note

  The clinician completes a comprehensive risk assessment note in the EHR within the timeframe required by facility policy (typically same-day or within 24 hours for outpatient).

  Required documentation elements (per Joint Commission NPSG 15.01.01):

  1. C-SSRS scores (ideation level, behavior items, dates)
  2. All identified risk factors (named individually)
  3. All identified protective factors (named individually)
  4. Clinical risk stratification level with rationale
  5. Completed SPI (attached or transcribed)
  6. Means restriction counseling — means discussed, client response, agreed plan
  7. Crisis contacts provided and verified
  8. Disposition and follow-up plan (appointment date, referrals, hospitalization)
  9. Collateral contacts made (family, prescriber, supervisor) with names and dates
  10. Clinician signature, credential, and date/time

  For High-risk cases: document supervisor or psychiatrist co-signature and the clinical rationale for the chosen disposition.

• Activate emergency response for imminent risk

  THIS STEP IS ACTIVATED ONLY WHEN RISK STRATIFICATION = IMMINENT (from Step 5).

  The clinician takes the following actions immediately and in parallel:

  1. Do not leave the client alone. If in-person, remain with the client or assign a staff member to maintain continuous observation.
  2. Notify supervisor or on-call psychiatrist immediately — provide client name, C-SSRS score, risk factors, and current location.
  3. For telehealth: Obtain the client’s confirmed physical address, call 911 and provide the address, and remain on the line with the client until emergency services arrive.
  4. Initiate involuntary hold paperwork (e.g., 5150 in California, Baker Act in Florida, or applicable state statute) if the client meets criteria and refuses voluntary hospitalization.
  5. Contact emergency services (911) if the client attempts to leave against medical advice and poses imminent danger to self.
  6. Document all actions in real time in the EHR, including times of notifications, names of personnel contacted, and client behavior.
  7. Complete a critical incident report per facility policy within 24 hours.

  Escalation contacts must be posted in every clinical interview room and accessible to all clinical staff.

• Schedule follow-up and coordinate care transitions

  The clinician schedules follow-up contact and coordinates care transitions before the client leaves the encounter, consistent with SAMHSA best practices for post-crisis continuity.

  Follow-up intervals by risk level:

  • Low risk: Follow-up appointment within 7 days; provide after-hours crisis line
  • Moderate risk: Follow-up appointment within 48–72 hours; consider same-day warm handoff to intensive outpatient or crisis stabilization
  • High risk: Follow-up within 24 hours; warm handoff to higher level of care; notify prescribing provider same day
  • Imminent risk: Hospitalization initiated (see Step 10); post-discharge follow-up appointment scheduled within 7 days of discharge

  Care coordination actions:

  • The clinician sends a secure message or calls the prescribing provider to communicate risk level and any medication quantity recommendations.
  • The clinician documents the follow-up appointment date and time in the EHR.
  • The clinician provides the client with a written reminder of the next appointment before they leave.
  • For clients with a case manager, the clinician sends a same-day notification of the risk assessment outcome.