Interpersonal Lack of privacy Being approached by ☐ men or women Yelling ☐Arguments ☐People Confined spaces touched People too close with Family ☐ ☐Being ☐ Being stared at Being ignored pressured Being ordered to do something ☐ ☐ ☐Feeling ☐ Being approached by women Being Teased/picked on Tall or large people Smells ☐ ☐ ☐ ☐ focusing on my symptoms ☐People Taste Time of Day Sights Sensations/textures Wringing Other Triggers ☐ ☐ ☐sounds ☐ ☐ ☐ Heart Pounding Shortness of Breath Breathing Hard hands ☐ ☐ ☐ ☐Wringing Clenching teeth Flushed/red face Crying fists Warning Signs of ☐ ☐ ☐ ☐Clenching Emotional legs sit ☐Bouncing ☐Singing ☐Can’t ☐Cursing/swearing Sweating Rocking ☐ ☐ ☐Pacing ☐Giggling Source of Information: Review ☐Respondent ☐Affiant ☐Chart ☐Other Suicide Assessment Friend or Family Member Completed Suicide: Prior Attempts: Approximate Date: Approximate Date: Method of attempt: Method of suicide: Source of Information: Review ☐Respondent ☐Affiant ☐Chart ☐Other Behaviors Exhibited by Respondent (If Yes, mark appropriate statement(s) below) History or Present Danger to Self Yes No ☐ ☐ Thoughts of suicide Threats of suicide Plan for Suicide with death ☐ ☐ ☐ ☐Pre-occupation Suicide gesture Suicide attempts Family history of suicide Self-mutilation ☐ ☐ ☐ ☐ Inability to care for self High risk behavior Provoking harm to self from others ☐ ☐ ☐ Other ☐ Describe: Violence Risk Assessment Current thoughts about harming another person Yes No ☐ If Yes, whom: If yes, how long have you had these thoughts If yes, specific plan: Access to means to carry out plan: Source of Information: Review ☐Respondent ☐Affiant ☐Chart ☐Other Violence Risk Factors Present Present Unknown Present Unknown Male Gender Substance Abuse ☐ ☐ ☐ ☐ Suspiciousness/Perception of hidden threat Comorbid MI & Substance Use Dx ☐ ☐ ☐ ☐ offense history Anger ☐ ☐ ☐ ☐ Psychopathy (PCL:SV>12) Antisocial Personality Diagnosis ☐ ☐ ☐ ☐ Violent Fantasies Frequency, type, recency ☐ ☐ Previous violence against other people ☐ ☐ Frequency, severity, type Frequency, severity Childhood physical abuse ☐ ☐ Source of Information: Review ☐Respondent ☐Affiant ☐Other
Interpersonal Lack of privacy ☐ Being approached by men or women ☐Arguments ☐People Yelling ☐ Confined spaces ☐Being touched ☐ People too close with Family ☐ Being stared at ☐ Being ignored ☐Feeling pressured ☐ Being ordered to do something ☐ Being approached by women ☐ Being Teased/picked on ☐ Tall or large people ☐ Smells ☐People focusing on my symptoms Other Triggers ☐ Taste ☐ Time of Day ☐sounds ☐ Sights ☐ Sensations/textures ☐ Wringing ☐ Heart Pounding ☐ Shortness of Breath ☐ Breathing Hard ☐Wringing hands Warning Signs of ☐ Clenching teeth ☐ Flushed/red face ☐ Crying ☐Clenching fists Emotional ☐Bouncing legs ☐Singing ☐Can’t sit ☐Cursing/swearing ☐ Sweating ☐ Rocking ☐Pacing ☐Giggling Source of Information: ☐Respondent ☐Affiant ☐Chart Review ☐Other Suicide Assessment Prior Attempts: Friend or Family Member Completed Suicide: Approximate Date: Approximate Date: Method of attempt: Method of suicide: Source of Information: ☐Respondent ☐Affiant ☐Chart Review ☐Other Behaviors Exhibited by Respondent History or Present Danger to Self ☐ Yes ☐ No (If Yes, mark appropriate statement(s) below) ☐ Thoughts of suicide ☐ Threats of suicide ☐ Plan for Suicide ☐Pre-occupation with death ☐ Suicide gesture ☐ Suicide attempts ☐ Family history of suicide ☐ Self-mutilation ☐ Inability to care for self ☐ High risk behavior ☐ Provoking harm to self from others ☐ Other Describe: Violence Risk Assessment Current thoughts about harming another person Yes ☐ No If Yes, whom: If yes, how long have you had these thoughts If yes, specific plan: Access to means to carry out plan: Source of Information: ☐Respondent ☐Affiant ☐Chart Review ☐Other Violence Risk Factors Present Present Unknown Present Unknown ☐ ☐ Male Gender ☐ ☐ Substance Abuse ☐ ☐ Suspiciousness/Perception of hidden threat ☐ ☐ Comorbid MI & Substance Use Dx ☐ ☐ offense history ☐ ☐ Anger ☐ ☐ Psychopathy (PCL:SV>12) ☐ ☐ Antisocial Personality Diagnosis ☐ ☐ Violent Fantasies Frequency, type, recency ☐ ☐ Previous violence against other people Frequency, severity, type ☐ ☐ Childhood physical abuse Frequency, severity Source of Information: ☐Respondent ☐Affiant Review ☐Other
revised-2016-Youth-Pre-Evaluation-Screening-form.docx