Suicide assessment for therapists to use with clients

If you’re in need of a suicidal ideation assessment to administer to clients, this article includes a downloadable suicide assessment for therapists that you can use in your practice.

Suicide is a leading cause of death in the United States and a significant public health concern globally. 

This article provides mental health clinicians with suicidal ideation assessment prompts, a list of suicide risk factors, and tips on how to assess for suicide. 

You can also download a free suicide assessment for therapists PDF to save to your electronic health record (EHR) and send to clients when needed. 

How to assess for suicide

Early detection of suicide risk is a crucial prevention strategy. The majority of people who die by suicide have seen a healthcare provider within months of their death, according to the National Institute of Mental Health. 

Suicide assessment occurs during numerous mental health interactions, like a mental health evaluation, consult, crisis call, or regularly scheduled therapy session. 

In other words, the nature of work as a therapist is always to be cognizant of suicide risk and protective factors. 

While there is no specific suicidal ideation test, there are numerous validated suicide screening tools that assess suicide risk and determine the level of care and intervention required. 

The particular steps involved in screening for suicide include:

1. Conduct a brief suicidal ideation assessment that includes questions about ideation, like “In the past few weeks, have you wished you were dead?” and “Have you had thoughts about killing yourself in the last couple of weeks?”
2. If risk is determined, proceed with a suicide safety assessment to include risk factors, previous history, details of ideation, plan, and intent. 
3. Determine risk level and next steps, which may involve a referral for a complete mental health evaluation, outpatient medical care, the creation of a safety plan, or no further action.

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Assessment of suicide risk

A suicidal ideation assessment involves looking at specific risk factors the client is facing, screening for ideation or behaviors, and understanding more about the intensity, acuity, and active nature of their ideation. 

Risk factors for suicide include:

• Individual risk factors: Previous suicide attempt, history of depression and mental health conditions, legal issues, physical health conditions, work-based stress, substance use, adverse childhood experiences, violence and victimization, impulsive or aggressive tendencies.
• Relationship risk factors: Bullying, loss of relationships, high conflict relationships, social isolation, family or loved one’s history of suicide.
• Community risk factors: Suicide in the community, lack of access to healthcare, community violence, historical trauma, stress of acculturation, and discrimination.
• Societal risk factors: Access to lethal means, unsafe portrayals of suicide in the media, and stigma associated with seeking help for mental health conditions.  

Screening tools for assessment of suicide risk

There are several standard evidence-based suicide assessments for therapists to assess the risk of suicidal ideation or behaviors, including:

The Columbia Suicide Severity Rating Scale (C-SSRS)

C-SSRS has a longer and shorter version. The detailed screening tool is used in clinical settings, crisis interventions, and research studies. The tool focuses on suicidal ideation, suicide behavior history, intensity of ideation, lethality of attempts, and risk factors. 

The shorter version of C-SSRS asks six questions: 

• Have you wished that you were dead or wished you would go to sleep and never wake up?
• Have you had any thoughts about killing yourself?

Depending on the answer to these screening questions, there are further assessment questions about plans and intent:

• Low risk: Have you done anything, started to do anything, or prepared to do anything to end your life? 
• Higher risk or positive answers prompt a series of questions to determine plans, intent, and preparatory steps: 
• Have you thought about how you might do this? 
• Have you had any intention of action on these thoughts of killing yourself as opposed to having the thoughts, but you definitely would not act on them?
• Have you started to work out or worked out the details of how to kill yourself? Do you intend to carry out this plan?

Ask Suicide-Screening Questions Brief Suicide Safety Assessment (ASQ BSSA)

Developed by the National Institute of Mental Health and designed for patients ages 10 or older, the ASQ tool has four screening questions:

1. In the past few weeks, have you wished you were dead?
2. In the past few weeks, have you felt that you or your family would be better off if you were dead?
3. In the past week, have you been having thoughts about killing yourself?
4. Have you tried to kill yourself? If yes, how? When?

Positive responses to any of the questions above leads to a question about acuity: Are you having thoughts of killing yourself right now? 

A further positive screening requires an immediate mental health evaluation and the removal of environmental risk factors, like access to potentially dangerous objects. 

If the client answers no, there is a further assessment (BSSA) that looks at the frequency of thoughts, suicide plan, past behavior, symptoms, social supports and stressors, and focuses on the creation of a safety plan. 

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Using the suicide assessment for therapists

Every agency, practice, and clinician can pick their preferred suicidal ideation assessment. 

Some psychologists argue that the suicide assessments for therapists are not an exact science and that there are different trajectories when we think about suicide. 

Others suggest the addition of a Patient Health Questionnaire-9 (PHQ-9) to screen for depression improves the identification of suicidal behavior. 

The PHQ-9 includes a risk question asking if the client has had thoughts that they would be better off dead or hurting themselves in some way. 

The most important aspect is understanding each individual’s circumstances, risk factors, the nature of their suicidal ideation, severity, and protective factors.

Whichever tool you choose, you can download and use the suicide assessment for therapists in several ways. You can print the suicide assessment for therapists to screen clients during the intake process, or use the tool in a crisis intervention. 

It’s important to direct clients to the following resources as well:

• 24/7 National Suicide Prevention Lifeline: 988 
• 24/7 Crisis Text Line: Text “HOME” to 741741

Sources

• American Academy of Pediatrics. (2023). Conducting a Brief Suicide Safety Assessment. 
• Centers for Disease Control and Prevention. (2024). Suicide Data and Statistics. 
• Centers for Disease Control and Prevention. (2024). Risk and Protective Factors for Suicide.
• Clay, R. (2022). How To Assess and Intervene with Patients at Risk of Suicide. American Psychological Association.
• Columbia University Department of Psychiatry. (2021). A Simple Set of 6 Questions to Screen for Suicide.
• National Institute of Mental Health. (n.d.). Ask Suicide-Screening Questions (ASQ) Toolkit.  

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