Please see attached.

Wk 4 – Risk Assessment Form
Assignment Content
When someone seeks treatment after trauma, counselors must complete a risk assessment, even when clients may not be demonstrating behaviors that seem high risk.

Assess risk for the client in the following case study using the Suicide Risk Assessment Form, which is based on the Suicide Assessment Five-step Evaluation and Triage from SAMHSA in this week’s learning activities. Use full sentences and appropriate grammar.

Katina is a 37-year-old heterosexual female of Serbian and Italian descent. She met Jonathan when she was in college, and they have had an on-and-off-again relationship over the past 15 years. During that time, they have had four children together, ages 4 to 13. She and Jonathan are currently working on their relationship and live together in the family home.

Katina states that she has experienced mental health problems since adolescence, and recently receiving a diagnosis of anxiety and depression. She reports having been abused during her childhood by a family friend, who was imprisoned briefly as a result, but never received counseling for it. When younger, Katina took party drugs to cope with her anxiety and depression but feels now that she has grown out of the habit.

Katina describes her long relationship with Jonathan as turbulent and dysfunctional. The abuse started as name calling; he would call her “fat,” “ugly,” and a “loser” if he felt he wasn’t getting his way or if he objected to her spending money. They had a joint bank account where Katina deposited her salary. If she didn’t pay bills and get household necessities immediately, Jonathan would clean out the account. As time went by, Jonathan’s abuse became physical. He frequently spat on Katina, pulled her hair, dragged her through the house, smashed her head into the wall, and threw drinks over her, on many occasions in front of the children. Throughout the relationship, she has experienced negative, controlling interference from Jonathan’s family, including verbal and physical abuse in the presence of the children as well.

Yesterday, Katina was attempting to pay bills and noticed that there was not enough money to cover the household expenses. When she brought it up to her husband, he told her she was just trying to get extra money out of him and called her a “mooch” and “too dumb to add 2+2.” As Jonathan approached her, their eldest child stepped in to shield her. The husband then struck the eldest child and they continued in a physical altercation. Per Katina’s report, the child has bruises and a black eye, but the police were not called, and she has not told anyone else about this occurrence.

Katina describes feeling guilty that she got her children involved in this situation. She explains that she wants everything to just go away. She describes feeling that, if she were not here any longer, everyone in her life would be much happier. Katina explains that she has these feelings often but never thought about a






Download this card and additional resources at

Resource for implementing The Joint Commission 2007 Patient
Safety Goals on Suicide

sAFe-T drew upon the American Psychiatric Association
Practice Guidelines for the Assessment and Treatment of
Patients with Suicidal Behaviors

Practice Parameter for the Assessment and Treatment of Children and
Adolescents with Suicidal Behavior. Journal of the American Academy
of Child and Adolescent Psychiatry, 2001, 40 (7 Supplement): 24s-51s


n Originally conceived by Douglas Jacobs, MD, and developed as
a collaboration between Screening for Mental Health, Inc. and
the Suicide Prevention Resource Center.

n This material is based upon work supported by the Substance
Abuse and Mental Health Services Administration (SAMHSA) under
Grant No. 1U79SM57392. Any opinions/findings/conclusions/
recommendations expressed in this material are those of the
author and do not necessarily reflect the views of SAMHSA.

National Suicide Prevention Lifeline

1-800-273-TALK (8255)

HHS Publication No. (SMA) 09-4432 • CMHS-NSP-0193
Printed 2009

Suicide Assessment Five-step

Evaluation and Triage


Note those that can be
modified to reduce risk


Note those that can be enhanced


Suicidal thoughts, plans,
behavior, and intent


Determine risk. Choose appropriate
intervention to address and reduce risk


Assessment of risk, rationale,
intervention, and follow-up

Substance Abuse and Mental Health Services Administration

Suicide assessments should be conducted at first contact, with any subsequent suicidal behavior, increased ideation, or pertinent clinical
change; for inpatients, prior to increasing privileges and at discharge.

3 suicidal behavior: history of prior suicide attempts, aborted suicide attempts, or self-injurious behavior

3 current/past psychiatric disorders: especially mood disorders, psychotic disorders, alcohol/substance abuse, ADHD, TBI, PTSD, Cluster B personality
disorders, conduct disorders (antisocial behavior, aggression, impulsivity)
Co-morbidity and recent onset of illness increase risk

3 Key symptoms: anhedonia, impulsivity, hopelessness, anxiety/panic, global insomnia, command hallucinations


3 Precipitants/stressors/Interpersonal: triggering events leading to humiliation, shame, or despair (e.g, loss of relationship, financial or health status—real
or anticipated). Ongoing medical illness (esp. CNS disorders, pain). Intoxication. Family turmoil/chaos. History of physical or sexual abuse. Social isolation

3 change in treat

CCMH/558 v3
Suicide Risk Assessment Form
CCMH/558 v3
Page 2 of 5

Suicide Risk Assessment Form
When someone seeks treatment after trauma, counselors must complete a risk assessment, even when clients may not be demonstrating behaviors that seem high risk.

Complete Parts 1 and 2 of this form including references. Submit the completed form for your assignment.
Part 1: Suicide Risk Assessment

Assess risk for the client in the case study using the Suicide Risk Assessment Form based on the Suicide Assessment Five-step Evaluation and Triage from SAMHSA in 175–260 words. Use full sentences and appropriate grammar.

Support your assessment with appropriate terminology from the DSM-5.

Part 2: Crisis Intervention and Safety Plan

Describe how you would apply the ABC model of crisis intervention in this situation in 260–350 words.

List the next steps you would take and what might be included in a safety plan for this individual in 50–100 words.

Cite the selected case and any other supporting resources used.

Format your citations and references according to APA guidelines.

Part 1: Suicide Risk Assessment
Step 1: Identify Risk Factors
What risk factors exist for this individual? Which factors can be modified to reduce risk?

Risk Factors


Precipitants and stressors

· Recent trauma, triggering events (real or anticipated), another prior crisis
· Medical illness, intoxication
· Family or interpersonal turmoil, history of physical or sexual abuse, social isolation
· Change in treatment or treatment provider, or discharge from psychiatric hospital

Enter notes here.

History of risk factors

· Attempts to die by suicide
· Self-injurious behavior
· Psychiatric disorders, comorbidity, and mental health treatments
· Attempts of family members to die by suicide
· Family diagnosed with Axis 1 psychiatric disorders that required hospitalization
Enter notes here.

Key symptoms

· Anhedonia
· Impulsivity
· Hopelessness
· Anxiety or panic
· Global insomnia
· Command hallucinations
Enter notes here.

Lethal Access

· Access to firearms or other lethal methods
Enter notes here.

Step 2: Identify Protective Factors
Which factors can be enhanced to protect the patient? Note: These protections may not counteract high risk factors.

Protective Factors



· Ability to cope with stress or frustration
· Spiritual beliefs
Enter notes here.


· Social supports
· Responsibility to loved ones, children, or pets
· Positive therapeutic relationships
Enter notes here.

Step 3: Conduct Suicide Inquiry
Has this individual had any ideations, plans, behaviors, or intentions to die by suicide? To what extent does the patient intend to carry out their plan? How lethal or self-injurious do they think their plan would be? What are their reasons to live or die?

Ask About



· Frequency, intensity, and duration of suicidal thoughts and ideations in:
a. the last 48 hours

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