QPRT- Adult- Pass/Discharge Assessment and Agreement

Client’s Name: Case Number: Date: Time:

Pass Assessment Discharge Assessment
Suicidal thoughts, feelings, and/or behaviors present? Yes No
* if Yes, complete QPRT re-evaluation form ONLY * if No, proceed with form
How are you feeling about this pass/discharge?
What are you planning to do while on pass/discharge?
Since your last pass, has anything substantial/significant(e.g. death in the family, divorce, etc)happened to you/your family?
Has anything happened in the past week that has been upsetting to you?
If anything were to make you upset while on pass/discharge, what would you do?
Who may be able to help you if you become upset?
Potential suicide risk factors present:
1. Assess current state of previous risk factors
2. Indicate new pass/discharge environmental factors / Wish to die
Access to means
Past suicide attempts
Hopelessness
Perceived burdensomeness
High-risk diagnosis
Agitation/Anxiety
Command hallucinations
Emotionally upset
Labile mood / Abuse history
Feeling deeply alone
Impulsive/Aggressive
Perfectionism
Sleep disturbance
Culture shock
Family problems
Perceived traumatic loss
School/Workproblems
Fearlessness about suicide / Demanding/Assaultive/Complaining
Cognitive distortions
Difficulty concentrating
Serious health problem
Drug/Alcohol abuse
Family history of suicidal behavior
History of violence to self and others
Unwilling/Unable to commit to safety
Other (explain)
Potential protective factors present:
1. Assess current state of previous protective factors
2. Indicate new pass/discharge environmental factors / Job security
Responsibility for children
Engaged in treatment
Duty to others
Good health
Supportive significant other / Medication compliance
Fear of death/pain
Sobriety
Difficult access to means
A sense of hope
Positive self-esteem / Pets
Religious prohibition
Calm environment
Best friend(s)
Safety agreement
Other (explain)
Safety Agreement
Client agrees to: (check all that apply)
To remain clean and sober until crisis passes
To follow professional advice, including medication regimen (if prescribed)
To not hurt or kill self accidentally or on purpose
To call at () or/and 911 in case of a crisis
To accept responsibility for this safety agreement
Other:
For Moderate/High Risk:
To remove (or see to the removal of) the means of suicide
OR
Unwilling/Unable to commit to safety
Client’s statement of agreement to safety (verbatim):
Client Signature:______Date/Time:______
If no signature, explanation:
Assessor: ______Signature:______Date/Time:______
Level of Risk / Check
box / Risk Management Plan
High /
  1. Line of sight supervision
  2. Psychiatric consult
  3. Means restriction (specify)
  4. Re-evaluation of risk at each session

Moderate /
  1. Increased supervision
  2. Clinical team consultation
  3. Means restriction (specify)
  4. Periodic re-evaluation

Low /
  1. Routine monitoring
  2. Routine means restriction
  3. Re-evaluation according to QPRT procedures
  4. Discuss low-risk status with clinical team

No Known Risk /
  1. Routine monitoring
  2. Routine means restriction
  3. Re-evaluation according to QPRT procedures
  4. Discuss no known risk status with clinical team

Other precautions/interventions: (check all that apply)
Client accepts literature on suicide prevention
Client accepts information about community resources
Client signs appropriate release/consent forms
Other:
Pass/Discharge Decision: Approved Denied
Justification for risk level (risk/benefit analysis):
Physician/Team discussions or additional comments:

If client is assessed to be at low or no known risk only, review this section for accuracy and initial here ______. “Client denies desire to hurt or kill himself or herself, and there are no substantial suicide risk factors present. The client is oriented to person, time, and place, sober, non-psychotic, attentive, and cooperative. The client was advised to inform me orat phone () should this change. The client was assessed to have the capacity to assess the risk and benefits of treatment and/or recommendations for same, and knows what to do in the event of worsening distress and the need to seek additional help. Referral information and numbers were provided if emergency response is needed.”

Assessor: ______Signature: ______Title: ______Date/Time: ______

QPRT

Adult Pass/Discharge Assessment and Agreement