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INTEGRATED ASSESSMENT BEHAVIORAL HEALTH

Attending or Consultant single choice
Attending Consultant
Gender single choice
MaleFemale
Male-to-Female TransgenderFemale-to-Male Transgender
Race single choice
African AmericanWhite
HispanicAsian
AfricanAmerican Indian
Pacific IslanderMultiracial
Facility single choice
Emergency DepartmentInpatient Setting
Outpatient SettingOutpatient Clinic
Crisis CenterNursing Home
Home
Employment Status single choice
UnknownFull-Time
Part-TimeUnemployed
Under-EmployedOut of the workforce
RetiredSelf-Employed
Housing Status single choice
UnknownIndependently
HomelessGroup Home
Nursing HomeCILA Home
Halfway HouseAssisted Living facility
ShelterAt Multiple Locations
With SpouseWith Family
With Both ParentsWith One Parent
With Friend
Marital Status single choice
UnknownMarried
SingleDivorced
SeparatedEstranged
WidowedCommon Law
Arrival Status single choice
AmbulancePolice
Inpatient psych unitSelf
Family
Reliability Status single choice
ReliableUnreliable
Questionably Reliable
Suicidal Ideations Status single choice
UnknownActive
PassiveDenied
Unable to Determine
Homicidal Ideations Status single choice
ActivePassive
DeniedUnable to Determine
Sex Offender Yes/No
Yes No
Inpatient Status single choice
ConservatorshipFiduciary
InvoluntaryLimited Guardianship
N/APlanary Guardianship
Temporary GuardianshipVoluntary
PRESENTING PROBLEM
Identified patient's perspective
Significant other's perspective
Precipitatin events
STRENGHTS/PROTECTIVE FACTORS
BARRIERS TO TREATMENT

MEDICAL HISTORY AND TREATMENT HISTORY

History of mental illness
Physical concerns, pre-existing medical conditions, physical disabilities and/or limitations
History of head trauma or concussion
Has patient ever been diagnosed with having a learning disability, pervasive developmental disability or mental retardation?
Pregnancy
Sexually Active
Sexual Orientation

PERSONAL HISTORY AND SUPPORT SYSTEM

Current Living Situation
Minor in care?
Identified support system (family, friends, etc)
History of military experience for self or family?
Currently receiving treatment throught VA system?
Family history of mental illness, chemical dependecy or suicide attempts/completed suicides?
Is patient a student?
Special Education needs (Academic/Behavioral)
Academic Performance
Other Support System Comments

RISK ASSESSMENT

SLEEP
APETITE
MOOD
ANXIETY
PSYCHOSIS

SUICIDE SCREENING

Ask questions 1 and 2. If both are negative, proceed to "Suicidal Behavior" section. If the answer to question 2 is "yes", ask questions 3, 4 and 5. If the answer to question 1 and/or 2 is "yes", complete "Intensity of Ideation" section below.
1. Wish to be Dead
Subject endorses thoughts about a wish to be dead or not alive anymore, or wish to fall asleep and not wake up.
Have you wished you were dead or wished you could go to sleep and not wake up?
If yes, describe:
2. Non-Specific Active Suicidal Thoughts
General Non-specific thoughts of wanting to end one's life/commit suicide (e.g, "I've thought about killing myself") without thoughts of ways to kill oneself/associated methods, intent, or plan during the assessment period.
Have you actually had any thoughts of killing yourself?
If yes, describe:
3. Active Suicidal Ideation with Any Methods (Not Plan) without Intent to Act
Subject endorses thoughts of suicide and has thoughts of at least one method during the assessment period. This is different than a specific plan with time, place or method details
worked out (e.g, thought of method to kill self but not a specific plan). Includes person who would say, "I thought about taking an overdose but I never made a specific plan as to when, where or how I would actually do it .... and I would never go through with it."
Have you been thinking about how you might do this?
If yes, describe:
4. Active Suicidal Ideation with Some Intent to Act, without Specific Plan
Active suicidal thoughts of killing oneself and subject reports having some intent to act on such thoughts, as opposed to "I have the thoughts but I definitely will not do anything about them."
Have you had these thoghts and had some intention of acting on them?
If yes, describe:
5. Active Suicidal Ideation with Specific Plan and Intent
Thoughts of killing oneself with details of plan fully or partially worked out and subject has some intent to carry it out.
Have you started to work out or worked out the details of how to kill yourself? Do you intend to carry out this plan?
If yes, describe:

INTENSITY OF IDEATIONS

The following features should be rated with respect to the most severe type of ideation (i.e, 1-5 from above, with I being the least severe and 5 being the most severe). Ask about time he/she was feeling the most suicidal
Lifetime Most Severe Ideation:
Recent Most Severe Ideation:
Frequency
Duration
Controllability
Deterrents
Reason for Ideation

INTENSITY OF IDEATIONS

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 commited, 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 gin is broken so no injury results, this is consdered an attempt. Inferring Intent: Even if an individual denies intent/wish to die, it may be inferred clinically from the behavior or cincumstances. 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 fllor/story). Also, if someone denies intent to die, but they thought that what they did could be lethal, intent may be inferred.

Have you made a suicide attempt?
Have you done anything to harm yourself?
Have you done anything dangerous where you could have died?
What did you do?
Did you _____ as a way to end your life?
Did you want to die (even a little) when you _____?
Were you trying to end your life when you _____?
Or Did you think it was possible you could have died from _____?
Or did you do it purely for other reasons / without ANY intention of killing yourself (like to relieve stress, feel better, get sympathy, or get something else to happen)?
(Self-Injurious Behavior without suicidal intent) If yes, describe:
Has subject engaged in Non-Suicidal Self-Injurious Behavior?
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 end your life but someone or something stopped you before you actually did anything?
Aborted or Self-Interrupted Attempt
When the person begin to take steps toward making a suicide attempt, but stops themselves before they acctually have engaged in ant 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 try to end your life but you stopped yourself before you actually did anything?
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 taken any steps towards making a suicide attempt or preparing to kill yourself (such as collecting pills, getting a gun, giving valuables away or writing a suicide note)?

SUICIDAL BEHAVIOR

(Check all that apply, so long as these are separate events; must ask about all types)
Actual Lethality/Medical Damage
What sort of reasons did you have for thinking about wanting to die or killing yourself? Was it to end the pain or stop the way you were feeling (in other words you couldn´t go on living with this pain or how you were feeling) or was it to get attention, revenge or a reaction from others? Or both?
Potentital 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 pontential 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).
Guidelines to Determine Level of Risk and Develop Interventions to LOWER Risk Level

RISK STRATIFICATION

HIGH RISK
Moderate Risk
Low Risk

POSSIBLE INTERVENTIONS

HIGH RISK
Moderate Risk
Low Risk

Suicide/Homicidal Risk Assessment:

Suicidal Ideation Assessment
Homicidal Ideation Assessment
Violence Risk Assessment
Place
Legal History

ABUSE/NEGLECT SCREENING

Have you ever been a victim of

Substance Abuse Screening

Section A: TWEAK: A validated tool to screen for risk in acohol use. To determine whether to administer the TWEAK, ask:
Section B: DAST 10: Please answer every question. If you have difficulty with a statement, then choose the response that is mostly right.
In the past 12 months
Section B: DAST 10: Please answer every question. If you have difficulty with a statement, then choose the response that is mostly right.