Suicide risk assessment in behavioral health: screening, tools, risk formulation and safety planning

If a client is in immediate danger, the assessment can wait. Call 911 or connect them to the 988 Suicide and Crisis Lifeline (call or text 988), and stay with them until help takes over. In Texas, every county's local mental health authority also runs a 24-hour crisis line and mobile crisis outreach.

Screening vs assessment

The two words get used interchangeably, and that's where charts go wrong: a program screens everyone, records "positive," and nothing else happens. NIMH's ASQ pathways lay the steps out as three tiers: a brief screen, then a brief suicide safety assessment for a positive screen, then a full mental health evaluation when that's needed (NIMH ASQ toolkit).

	Screening	Assessment
Purpose	Find who may be at risk	Decide how much risk, why, and what to do
Who	Everyone served, at the points your policy sets	Everyone who screens positive (and anyone a clinician is worried about)
By whom	Any staff member trained on the tool	A clinician your policy names as qualified, within their license
How long	Under a minute to a few minutes	From a 10-minute brief assessment to a full evaluation
Output	Positive or negative, sometimes a triage level	A risk formulation and a plan
Tools	C-SSRS screener, ASQ, PHQ-9 item 9 (as a trigger)	Full C-SSRS, ASQ Brief Suicide Safety Assessment, SAMHSA SAFE-T, clinical interview, collateral

One instrument can do both jobs: the Joint Commission's FAQ on evidence-based assessment says screening and assessment can be met by a single process that screens for ideation and assesses its severity at once, and its screening FAQ notes the C-SSRS can be used for both.

Validated tools compared: C-SSRS, ASQ and PHQ-9 item 9

Tool	From	What it covers	Cost and training	After a positive
C-SSRS (Columbia Protocol)	The Columbia Lighthouse Project	Graded questions on wish to be dead, active thoughts, method, intent, plan and suicidal behavior. Screener and full versions, "since last contact" versions with triage for outpatient programs, all ages, in more than 150 country-specific languages.	Free for community and healthcare settings, with free training (the shortest is about 20 minutes). Training isn't required and no mental health experience is needed to ask the questions, though the project recommends training.	The triage points on the version you use, then a clinician's assessment
ASQ (Ask Suicide-Screening Questions)	National Institute of Mental Health	Four yes-or-no questions about recent suicidal thoughts and past attempts, plus one acuity question if any answer is yes. Validated for youth and adult medical patients, with outpatient pathways. The outpatient youth pathway screens patients 10 and older who meet its criteria.	Free from NIMH, with pathways, scripts and the Brief Suicide Safety Assessment (BSSA).	"Acute positive" (yes to the acuity question): a STAT safety evaluation, and the patient can't leave until evaluated. "Non-acute positive": the BSSA, about 10 minutes.
PHQ-9 item 9	The PHQ-9 depression questionnaire	One item asks how often, over the last two weeks, the person has had thoughts of being better off dead or of hurting themselves. It's a depression item, not a suicide screen, and it mixes passive thoughts of death with self-harm.	Often already in the intake packet. The Joint Commission's screening FAQ lists the PHQ-9 among example tools.	Treat any answer above "not at all" as positive and follow it with a C-SSRS or a clinician's assessment

What item 9 can and can't tell you. In a study of 84,418 outpatients aged 13 and older, the one-year risk of a suicide attempt rose from about 0.4% for those answering "not at all" to about 4% for "nearly every day," and the risk of suicide death from about 0.03% to 0.3%, after adjusting for age, sex, treatment history and depression severity (Simon et al., Psychiatric Services, 2013). So a positive answer matters and should never sit unread, but most people who answer yes won't make an attempt, and a "not at all" doesn't rule risk out. That's why item 9 works as a trigger for a real screen, not as the screen.

How we use them at a licensed Texas outpatient program we run: the PHQ-9 and GAD-7 at intake and on a schedule; any item 9 answer above "not at all" stays on the clinician's list until a C-SSRS is done that day or after; the C-SSRS at intake and with the "since last contact" version when risk was found; and a positive C-SSRS gets a safety plan the same day. Use each tool exactly as written: the Joint Commission warns that small wording changes can change a validated tool's accuracy (the NPSG.15.01.01 guide covers when to screen).

What the assessment has to answer

The Joint Commission's FAQ says an evidence-based assessment asks directly about suicidal ideation, plan, intent, suicidal or self-harm behavior, risk factors and protective factors, and records how the level of risk was decided. SAMHSA's SAFE-T puts the same work in five steps. In practice, the clinician needs answers to these questions before writing a risk level:

• Thoughts: passive (wishing to be dead) or active? How often, how long, how intense, how controllable? What's different about today?
• Method and plan: has the person thought about how, when or where? Have they taken any step: researching, buying, rehearsing, writing a note, giving things away?
• Intent: do they intend to act? What stops them? (The answer is often a protective factor you'll put in the plan.)
• Behavior: past attempts, interrupted or aborted attempts, self-harm, and overdoses, including ones the client calls accidental.
• Risk factors and warning signs: current symptoms (hopelessness, agitation, insomnia, psychosis), recent losses, intoxication or withdrawal, a return to use, legal or custody events, isolation, chronic pain.
• Protective factors: reasons for living, people, children or pets, faith, engagement in treatment, future plans, and the client's own ability to use a safety plan.
• Access to lethal means: firearms in the home or available elsewhere, stockpiled or prescribed medications, opioids, and whether naloxone is in the home.
• Collateral: what family, a referring provider or records add. In a substance use program, get the client's written consent first (42 CFR Part 2), unless it's a medical emergency.

Risk formulation: acute and chronic risk, and why

A risk level with no reasoning is the weakest line in a chart. A formulation states the level and the reasons, and points at what can change. Pisani, Murrie and Silverman argue for exactly that shift, from predicting who will die to formulating risk in a way that guides prevention ("Reformulating Suicide Risk Formulation: From Prediction to Prevention," Academic Psychiatry, 2016).

The VA's Therapeutic Risk Management risk stratification table (Rocky Mountain MIRECC; current tool dated June 2024) is a practical model. It rates risk on two axes, severity and time:

Level	What it describes
High acute risk	Suicidal ideation with intent to die, and unable to maintain safety without outside help. Typically calls for psychiatric hospitalization, voluntary or involuntary.
Intermediate acute risk	Suicidal ideation, but able to maintain safety without outside help. It may differ from high risk only by the absence of intent, for an identified reason.
Low acute risk	Possible ideation without current intent, no specific current plan and no recent preparatory behavior, with high confidence in the person's safety from the person and other sources.
Chronic risk (rated separately)	The baseline risk of becoming acutely suicidal, often under stress: chronic mental health conditions, chronic pain or illness, chronic ideation, prior attempts, substance use disorder, limited reasons for living or coping skills, unstable circumstances. Managed by strengthening protective factors and reducing modifiable risk factors.

Many clients in substance use treatment carry high chronic risk (a prior overdose, a substance use disorder, losses) while their acute risk on a given day is low. Writing both levels keeps the chart honest and the plan specific. No scale makes the decision for you: the 2024 VA/DoD guideline found no evidence to recommend one risk assessment or stratification tool over another (VA/DoD Clinical Practice Guideline, 2024).

From risk level to response in an outpatient program

What we write into our own outpatient and IOP procedures. Adapt it to your setting, staffing and policy; it isn't a substitute for clinical judgment.

Acute risk	Response the same day	Then
High	Never leave the person alone. Call 911 or mobile crisis, or arrange a hospital evaluation; tell the clinical director. An outpatient program isn't the right level while risk is imminent.	Coordinate with the hospital; plan the return or step-down before discharge.
Intermediate	A written safety plan built with the client, lethal means counseling, crisis numbers, family involvement with consent, a clinical director consult; consider a higher level of care.	More contact (sessions moved up, a call between program days), reassessment with the "since last contact" screener at each contact, a safety problem on the treatment plan.
Low	Document the reasoning. Review or start a safety plan if chronic risk is elevated or the client wants one; crisis numbers either way.	Rescreen on the schedule your policy sets and at any change: a return to use, a loss, a step down, discharge.

The Stanley-Brown Safety Planning Intervention

The Safety Planning Intervention (SPI), developed by Barbara Stanley and Gregory K. Brown, is a brief intervention: the clinician and client write, together and in the client's words, a prioritized list of coping strategies and people to turn to, for use when suicidal thoughts come back. The original paper describes it as taking about 20 to 45 minutes (Stanley and Brown, Cognitive and Behavioral Practice, 2012).

• What it covers: recognizing warning signs; coping strategies the person can use alone; people and social settings that distract; people to ask for help; professionals and crisis services, including 988; and making the environment safer, which is where lethal means counseling comes in. The order matters: the person tries their own steps first and moves down the list.
• The evidence: in VA emergency departments, patients who got the SPI plus structured follow-up phone calls were about half as likely to show suicidal behavior over six months as comparable patients who got usual care, and more than twice as likely to attend outpatient mental health treatment. It was a cohort comparison, not a randomized trial (Stanley et al., JAMA Psychiatry, 2018).
• The form is copyrighted. The Stanley-Brown Safety Plan form notes that individual use is permitted, but organizations that want to adapt it, build it into an EHR or use it for profit must ask the authors' permission, and only authorized translations should be used. The VA's safety plan worksheet follows the same structure.
• Training: the developers offer tiered training, up to a competency-based program.

What makes a safety plan work in a chart review: it's in the client's words, not a form with "call 988" on every line; it names real people with phone numbers; it lists the program's number and the county crisis line; the client has a copy (paper or a photo on their phone); and later notes show it being reviewed and changed. A plan written once at intake and never mentioned again is the finding we see most.

Lethal means counseling and CALM

Lethal means counseling is a conversation with the client (and, with consent, family) about reducing access to the most dangerous methods while risk is high: firearms, stockpiled medications, and in a substance use program, opioids. The Action Alliance's Recommended Standard Care treats it as a central part of safety planning and notes that reducing access to lethal means has repeatedly been shown effective in community-wide suicide prevention.

• The training: CALM (Counseling on Access to Lethal Means) is a free, self-paced online course from Education Development Center, now on its Zero Suicide training site. It takes about two hours, the certificate needs a passing posttest score of 80% or higher, and it doesn't carry continuing education credit. It covers who could benefit, how to ask about access, how to work with clients and families to reduce it, firearm storage options off-site and at home, and limiting access to dangerous medications.
• How to ask: ask everyone at elevated risk, plainly and without judgment: "Is there a gun in your home, or one you could get to? Who else has access? Are there pills at home you don't need, or more than a week's supply?" Then agree on a step: who will hold the firearm or the key, who will hold or dispose of the medicine, and when.
• For clients who use opioids: naloxone in the home, and family who know how to use it, belong in the plan.
• Write down the outcome, not just "means discussed": what the client agreed to, who is doing it, and when you'll check.

Documentation, with a sample note

The test of a suicide risk note is simple: could the next clinician, or a surveyor, see the risk, the reasoning and the plan in one minute? The VA publishes risk stratification documentation examples worth reading. Every note should carry:

• The date, time, who did it, and what prompted it (intake, a positive screen, a disclosure).
• The screen used and the answers or score.
• Ideation, plan, intent, preparatory behavior and past behavior, in specific terms.
• Risk factors, warning signs and protective factors, and any collateral (with the consent noted).
• The formulation: acute and chronic risk levels, with the reasons for each.
• The plan: the safety plan (and that the client has a copy), lethal means counseling and its outcome, the level of care decision and why, who was consulted or told, and the next contact and reassessment date.

A sample note, for a made-up client in an IOP: 10/28 9:40 a.m. C-SSRS screener (since last contact) positive for wish to be dead and non-specific active thoughts in the past week; denies method, plan, intent or preparatory behavior; no behavior in the past 3 months. Lifetime: overdose in 2024, client unsure if intentional. Risk factors: alcohol use disorder, last drink 10/12; job loss 10/20; lives alone; poor sleep. Protective: daughter, weekly contact; attending IOP; "I want to be there when my grandson is born." Means: no firearms in the home or available (client); about 20 leftover sleeping pills at home. Collateral: daughter by phone with the client's signed consent; confirms no firearms. Formulation: acute risk intermediate (current ideation, no intent, can stay safe with a plan); chronic risk high (prior overdose, alcohol use disorder, isolation). Modifiable: drinking, sleep, isolation, the pills. Plan: safety plan written with client, copy given and photographed on her phone; daughter will take the pills Saturday, client will confirm Monday; naloxone kit given; 988 and the county crisis line on the plan; individual session moved to Thursday; C-SSRS since last contact each program day this week; clinical director informed; referral to the psychiatric NP for sleep. Reassess 10/30.

Put the risk level where it can't be missed: a chart flag, the problem list, the top of the next note. A risk level buried in an intake narrative is how a positive screen gets lost.

Follow-up: reassessment, transitions and caring contacts

• Reassess on a schedule and at every change. The C-SSRS "since last contact" versions are built for this. Write when risk comes down, and why, as carefully as when it went up.
• Caring contacts. The Action Alliance's Recommended Standard Care says most people with suicide risk should get brief interventions such as safety planning and caring contacts, and its care transitions report says people leaving a care setting should get follow-up contact. Caring contacts can be postcards, letters, emails, texts or calls.
• Missed days are a clinical event. A client at risk who doesn't show gets a call the same day and a documented attempt to reach them. NIMH's outpatient youth pathway, for example, includes a follow-up visit in 3 days to confirm safety and whether a mental health connection was made (NIMH).
• Transitions and discharge: rescreen on the last day, update the safety plan, hand off to a dated appointment. The NPSG guide's discharge section has the checklist.

Our own chart check looks for four failures, and they're the ones to audit first: no C-SSRS at intake; a positive screen with no safety plan the same day; no rescreen after a positive; and a positive screen that later notes and the treatment plan never mention again.

How it maps to NPSG.15.01.01

For Joint Commission-accredited programs, this work is how you meet the suicide prevention goal's elements of performance. The NPSG.15.01.01 guide covers each one in full; here's where each section above fits:

Element of performance	This guide	In depth
EP 1: environment	Not covered here	Ligature risk assessment
EP 2: screen everyone with a validated tool	Tools compared	When to screen
EP 3: evidence-based assessment of positives	What the assessment answers	EP 3
EP 4: document risk level and mitigation plan	Formulation, safety plan, sample note	EP 4
EP 5: training, reassessment, monitoring	C-SSRS, SPI and CALM training; response by level	EP 5
EP 6: discharge counseling and follow-up	Lethal means, follow-up	EP 6
EP 7: monitor and improve	The four chart failures above	Chart audit checklist

In Texas, 26 TAC 564 doesn't name a suicide screening tool for licensed chemical dependency programs; the screen sits inside the assessment and the mental health referral duty (Cima Consulting's 26 TAC 564 requirements guide), and a suicide attempt by an active client is a reportable incident (see incident reporting timelines).

Where Comply and Cima EHR fit

Comply keeps the program side of suicide risk work on schedule without holding client information: yearly suicide risk screening training for each clinical staff member with the proof stored, the quarterly chart review that checks the admission screen and a safety plan wherever risk was found, and the incident review, all filed in the survey binder and laid out across the year in the compliance calendar. On the clinical side, Cima EHR's screenings put a red safety card on the clinician's Today screen and send an email when a client answers above "Not at all" on the PHQ-9 self-harm question, and a note with a moderate or high risk rating can't be signed without a safety plan.

Need the written procedure? Cima Consulting's program policy and procedure manual ($7,500) includes the suicide risk screening and reduction policy, and a mock survey ($6,500) traces a positive screen through your charts the way a surveyor would.

Questions

What is a suicide risk assessment?

A clinician's evaluation of a person's suicide risk, usually after a positive screen: direct questions about suicidal thoughts, plans, intent and past behavior, a review of risk factors, warning signs and protective factors, a documented level of acute and chronic risk with the reasons, and a plan to reduce the risk.

What's the difference between suicide screening and a suicide risk assessment?

Screening is brief and given to everyone to find who may be at risk. Assessment is a clinician's fuller evaluation of the people who screen positive, ending in a risk formulation and a plan. One tool, such as the C-SSRS, can do both.

What are the levels of suicide risk?

Most programs use low, moderate (or intermediate) and high. The VA's risk stratification table also separates acute risk (right now) from chronic risk (the person's baseline), and rates each as low, intermediate or high.

Which suicide risk assessment tool is best?

There's no single best one. The 2024 VA/DoD guideline found no evidence to recommend one risk assessment or stratification tool over another. Use a validated screen (C-SSRS or ASQ, for example), a structured assessment and clinical judgment, and use each tool as written.

Is the PHQ-9 a suicide risk assessment?

No. It's a depression questionnaire. Its item 9 asks about thoughts of being better off dead or of self-harm, and a positive answer is linked to higher risk, so treat any answer above "not at all" as a trigger for a C-SSRS or a clinician's assessment.

Who can do a suicide risk assessment?

Screening can be done by any trained staff member; the C-SSRS needs no mental health experience to ask. The assessment should be done by a clinician your written policy names as qualified, within the scope of their license.

How do you document a suicide risk assessment?

Record what prompted it, the screen and answers, ideation, plan, intent and behavior, risk and protective factors, collateral, the acute and chronic risk levels with reasons, and the plan: safety plan, lethal means counseling, level of care, who was told, and the reassessment date.

Is the Stanley-Brown Safety Plan free to use?

Individual use of the form is permitted. Organizations that want to adapt it, build it into an electronic record or use it for profit need the authors' permission, and only authorized translations should be used.

What is CALM training?

Counseling on Access to Lethal Means: a free, self-paced online course of about two hours that teaches clinicians how to ask about firearms and medications and work with clients and families to reduce access while risk is high.

More in this set: NPSG.15.01.01 suicide risk reduction, the ligature risk assessment, sentinel events and root cause analysis and the chart audit checklist.

Sources

• The Columbia Lighthouse Project: The Columbia Protocol for healthcare and community settings, About the protocol, Free training.
• National Institute of Mental Health: ASQ Toolkit; ASQ information sheet; Youth outpatient suicide risk screening pathway.
• Simon GE et al., "Does response on the PHQ-9 Depression Questionnaire predict subsequent suicide attempt or suicide death?" Psychiatric Services 2013;64(12):1195-1202.
• The Joint Commission, standards FAQs: screening requirements (BHC); use of an evidence-based process to assess risk.
• SAMHSA, SAFE-T pocket card (SMA09-4432).
• U.S. Department of Veterans Affairs, Rocky Mountain MIRECC: Risk stratification table, Therapeutic Risk Management risk stratification tool (June 2024), documentation examples; VA/DoD, Clinical Practice Guideline for the Assessment and Management of Patients at Risk for Suicide (2024); VA safety plan worksheet.
• Pisani AR, Murrie DC, Silverman MM, "Reformulating Suicide Risk Formulation: From Prediction to Prevention", Academic Psychiatry 2016;40(4):623-629.
• Stanley-Brown Safety Planning Intervention: suicidesafetyplan.com, forms and training; Stanley B, Brown GK, "Safety Planning Intervention: A Brief Intervention to Mitigate Suicide Risk", Cognitive and Behavioral Practice 2012; Stanley B et al., "Comparison of the Safety Planning Intervention With Follow-up vs Usual Care of Suicidal Patients Treated in the Emergency Department", JAMA Psychiatry 2018 (full text).
• Suicide Prevention Resource Center, CALM: Counseling on Access to Lethal Means; Education Development Center, CALM course.
• National Action Alliance for Suicide Prevention: Recommended Standard Care for People with Suicide Risk; Best Practices in Care Transitions for Individuals with Suicide Risk.
• Texas HHSC, mental health crisis services; eCFR, 42 CFR Part 2; 988 Suicide and Crisis Lifeline.

The client and note are made up. This guide is general information, not clinical or legal advice; follow your own policy, your licensing rules and the official instruments. Comply isn't affiliated with or endorsed by The Joint Commission, NIMH, SAMHSA, the VA, Columbia University, the developers of the Safety Planning Intervention, EDC or the Action Alliance.