Patient Name:______
Date:______
Suicidal Ideation Assessment and Disposition Note
(to be filed in clinical file as a session note)
Patient noted Suicidal ideation in (testing responses / universal symptoms checklist / interview )
Patient was referred for evaluation for hospitalization to (agency) ______at (phone no.)______because:
The patient admitted the ideations were occurring as recently as ______,
The patient admitted the ideations were occurring as frequently as______times per (day / week / month ),
The patient admitted to suicidal ideation with planning
The patient has taken steps to attempt to implement plan
(gotten into car with the intent of crashing)
(hoarded pills)
(attempted to acquire weapon)
(______)
The patient has ready means available to implement plan
(medication, vehicle, other ______)
The patient is also reporting auditory hallucinations
The patient admitted to having command type auditory hallucinations,
The patient has history of past suicidal attempts,
The patient reports family history of suicide,
The patient reports insufficient social support and no assistance at home is available to help monitor safety whom patient is willing to involve,
The patient has no identifiable motivation to control impulses of self harm
The patient denies having confidence in ability to control impulses to harm self,
The patient is requiring services beyond the scope of this practice and will be closed out of services with recommendation that the (primary physician / applicant’s attorney) refer patient to a more appropriate level of care.
The patient will be closed out of services effective immediately due to the determination that he / she is not appropriate for the services provided at this agency and, should the patient stabilize with regard to suicidal ideations in the future, he / she should be referred back for reassessment to determine if he / she is appropriate for our services at that time.
______
Doctor’s signatureDateLicense number
Patient Name:______
Date:______
Suicidal Ideation Assessment and Disposition Note
(to be filed in clinical file as a session note)
Patient noted Suicidal ideation in (testing responses / universal symptoms checklist / interview )
The patient was not referred for evaluation for hospitalization because:
The patient denies suicidal ideations are current and reports not having suicidal ideation since ______,
The patient reported suicidal ideations are infrequent occurring ______times per month / week ,
The patient denied planning as part of suicidal ideations,
The patient admitted to plan which was poorly thought out and unrealistic
The patient has no access to the means to implement the plan,
There are no signs of psychotic processing evident in session,
The patient denied having command type auditory hallucinations,
The patient has no history of past suicidal attempts,
The patient reports no family history of suicide
The patient was able to verbalize identifiable and sufficient motivation to control impulses to harm self, ______
The patient verbalized confidence in ability to control impulses to harm self,
The patient has adequate social support and is willing to involve them in monitoring and maintaining patient’s safety, ______
(other comments)______
______
The patient has been supplied with phone numbers to appropriate crisis services and agreed to a plan to access help through the provided channels if patient’s condition with regard to suicidal ideation decompensates,
The patient will be followed up more frequently to monitor safety with next appointment scheduled on ______to see ______.
The patient’s care will require weekly review of his/her patient records by a psychologist to monitor progress and ongoing risk.
Due to the absence of report of ongoing suicidal thoughts, the patient’s care will not require weekly review of his/her patient records by a psychologist to monitor progress and ongoing risk.
The patient is requiring services beyond the scope of this practice and will be closed out of services with recommendation that the (primary physician / applicant’s attorney ) refer patient to a more appropriate level of care.
The patient will be closed out of services effective immediately due to the determination that he / she is not appropriate for the services provided at this agency and, should the patient stabilize with regard to suicidal ideations in the future, he / she should be referred back for reassessment to determine if he / she is appropriate for our services at that time.
______
Doctor’s signatureDateLicense number