Columbia Suicide Severity Rating Scale Assessment Form

Step 1: Identify Risk Factors

C-SSRS Suicidal Ideation Severity

In Last Month?

Wish to be dead

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

Current suicidal thoughts

Have you actually had any thoughts of killing yourself?

Suicidal thoughts w/ Method (w/no specific Plan or Intent or act)

Have you been thinking about how you might do this?

Suicidal Intent without Specific Plan

Have you had these thoughts and had some intention of acting on them?

Intent with Plan

Intent with Plan Have you started to work out or worked out the details of how to kill yourself? Did you intend to carry out this plan?

C-SSRS Suicidal Behavior: "Have you ever done anything, started to do anything, or prepared to do anything to end your life?”

Examples: 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 or it was grabbed from your hand, went to the roof but didn’t jump; or actually took pills, tried to shoot yourself, cut yourself, tried to hang yourself, etc.

If “YES” Was it within the past 3 months?

Step 2: Identify Protective Factors (Protective factors may not counteract significant acute suicide risk factors)

Step 3: Specific questioning about Thoughts, Plans, and Suicidal Intent – (see Step 1 for Ideation Severity and Behavior)

C-SSRS Suicidal Ideation Intensity (with respect to the most severe ideation 1-5 identified above)

Frequency

Duration

Controllability

Deterrents

Reasons for Ideation

Total Score:

Step 4: Guidelines to Determine Level of Risk and Develop Interventions to LOWER Risk Level

The estimation of suicide risk, at the culmination of the suicide assessment, is the quintessential clinical judgment, since no study has identified one specific risk factor or set of risk factors as specifically predictive of suicide or other suicidal behavior.” From The American Psychiatric Association Practice Guidelines for the Assessment and Treatment of Patients with Suicidal Behaviors, page 24.

RISK STRATIFICATION TRIAGE

High Suicide Risk

Moderate Suicide Risk

Low Suicide Risk
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