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Suicide Assessment form
Suicide Assessment Form
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* Indicates required question
Email
*
Your email
INSITE Integrative Services LLC
Date:
*
MM
/
DD
/
YYYY
Name
*
Your answer
In the past few weeks, have you wished you were dead?
*
Yes
No
Required
In the past few weeks, have you felt that you or your family would be better off if you were dead?
*
Yes
No
Required
In the past week, have you been having thoughts about killing yourself?
*
Yes
No
Required
Have you ever tried to kill yourself?
*
yes
no
If Yes, How and when?
Your answer
Are you having thoughts of killing yourself right now?
*
yes
No
Required
If yes, please describe:
Your answer
I have thoughts to harm another person.
*
Yes
No
Required
If I believe I will act on my feelings to harm myself or another, I will call 911 or go to the nearest hospital emergency
*
Yes
NO
Required
A copy of your responses will be emailed to the address you provided.
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