Suicide Assessment Five Step Evaluation and Triage (SAFE-T)

Patient Name: _____________________________________ DOB : ___/___/___ Today’s Date: ___/___/___

1. Risk Factors Note those that can be modified to reduce risk

Suicidal behavior
none
past attempts
aborted attempts
rehearsals
self-harm

Current/past psychiatric diagnoses and treatment

Key symptoms

anhedonia
panic attacks

impulsivity
global insomnia

hopelessness
command hallucinations

anxiety

Family history of suicidal behavior
none
History includes:

Precipitants/stressors/interpersonal

academic
major loss

family
major trauma

relationships/ social
financial

reputational
legal

vocational

Change in
none
discharge from psych facility
non-compliance with RX
recent RX change
Treatment

Risk Behaviors
none
substance abuse
alcohol
self-harm
inappropriate sexual behavior

Access to weapons, sharps, meds (RX/OTC)

Copyright© 2015 by Girls to Women Health and Wellness. All Rights Reserved. Based on Suicide Assessment Five-Step Evaluation and Triage (SAFE-T). Go to SPRC.org for more information.
2. Protective Factors Note those that can be enhanced
Internal
ability to cope with stress
religious beliefs
frustration tolerance
absence of psychosis

External
responsibility to family or pets
positive therapeutic relationships
social supports

3. Suicide Inquiry Suicidal thoughts, plans, behavior and intent

Last 48 Hours Past Month Worst Ever
Frequency
Ideation
Intensity
Duration
Current Plan
none
timing
location
lethality
availability
preparatory acts

Behaviors
none
past attempts
aborted attempts
rehearsals
self-harm

Current Intent
none
expects to carry out plan
believes plan is lethal
believes plan is self-injurious

Reasons to die
Reasons for live

Copyright© 2015 by Girls to Women Health and Wellness. All Rights Reserved. Based on Suicide Assessment Five-Step Evaluation and Triage (SAFE-T). Go to SPRC.org for more information.
4. Risk Level Determine risk. Choose appropriate intervention to address and reduce risk

Risk/Protective Factors Suicidality Possible Interventions

High Psychiatric disorders with severe Potentially lethal suicide Admission generally indicated unless a
symptoms, or acute precipitating attempt or persistent significant change reduces risk.
event; protective factors not ideation with strong intent Suicide precautions
relevant or suicide rehearsal
Moderate Multiple risk factors, few Suicidal ideation with plan, Admission may be necessary depending on
protective factors but no intent or behavior risk factors. Develop crisis plan.
Give emergency/crisis numbers
Low Modifiable risk factors, strong Thoughts of death, no Outpatient referral, symptom reduction.
protective factors plan, intent or behavior Give emergency/crisis numbers

5. Document Treatment Plan Assessment of risk, rationale, intervention and follow-up (ECW browse text setup)
Risk/Protective Factors
High
Moderate
Low

Suicidality
High
Moderate
Low

Intervention Level
High
Moderate
Low

Medication

Suicide Precautions Advised

Daily close monitoring and supervision, ongoing consistent contact with safe individuals, restrict access to weapons (including firearms, knives, ropes,
dangerous machinery, etc.) and medications (Rx and OTC). Counseled on supportive strategies to ensure safety and minimize conflict while arranging
for further assessment or monitoring for response to treatment.

Suicide Prevention Plan Provided

Crisis Plan Developed with Patient

Follow-up (who and when)

GTW
Psychiatrist
Therapist
Hospital
Treatment Center

Copyright© 2015 by Girls to Women Health and Wellness. All Rights Reserved. Based on Suicide Assessment Five-Step Evaluation and Triage (SAFE-T). Go to SPRC.org for more information.