Professional Documents
Culture Documents
Srs - English - 140 Suicide Risk Assessment
Srs - English - 140 Suicide Risk Assessment
Srs - English - 140 Suicide Risk Assessment
SRA
Instructions
We realize what a difficult time this is for you.
Nevertheless, we need more information so we
can fully understand the extent of the problems
you have been struggling with.
All questions in this questionnaire should be
answered. These results are confidential. Do
not skip any questions. Your cooperation in
completing this questionnaire is appreciated.
Anticipate approximately 20 to 25 minutes to
complete.
You May Begin.
Section 1
Answer the following questions True or False.
When a statement is true, put an X under T for True.
When a statement is false, put an X under F for
False on your answer sheet.
1. There are times when I worry about what other
people think, or say about me.
2. In the last year, using drugs has been a problem
for me.
3. I have shared my suicidal intentions (verbally
or in writing) with another (or others)
4. It bothers me, when I am overlooked or ignored
by people I know.
5. People tell me I seem to be troubled, worked
up, or preoccupied much of the time.
6. My family has a history of suicide.
46.
Section 2
Select the answer to each of the following statements
that is accurate for you. Put an X under the number
(1, 2, 3, 4 or 5) that applies to you now.
86. With regard to your suicidal thoughts, select
the answer that is most accurate for you.
1. I dont think or talk about suicide.
2. My suicidal thoughts are infrequent and, of
low intensity and short duration.
3. My frequent suicidal thoughts have limited
intensities and short durations.
4. I do not discuss my frequent, intense and
enduring suicidal thoughts with anyone.
5. I have discussed my suicidal thoughts with
another (doctor, counselor, friend or close
relative).
87. My intention to kill myself is:
1. Diminishing and weakening.
2. Unchangeable or unalterable.
3. Increasing and getting stronger.
4. Accelerating rapidly.
5. I do not intend to kill myself.
88. Prior to this assessment, I have been diagnosed
as having (select one):
1. A personality disorder.
2. An alcohol (drinking) problem.
3. A drug problem.
4. All of the above (1, 2 and 3).
5. None of the above.
89. The following support system is available to
me (select one):
1. Doctor, therapist or counselor.
2. Social (family/friends) support.
3. Support group meetings.
4. All of the above (1, 2 and 3).
5. None of the above.
90. Within the last six years, I have been
diagnosed with, or treated for (select one):
1. Depression.
2. A bipolar disorder.
3. Schizophrenia.
4. All of the above (1, 2 and 3).
5. None of the above.
Section 3
Rate each statement as it applies to you now. Put
an X on your answer sheet, under the number that
you select for your answer. Use the following
rating scale.
1. Rare or Never
2. Sometimes
3. Often
4. Very Often or Always
SRA
First Name: ____________________ Middle Initial: ________ Last Name: ___________________________
Last Four Digits of Your Social Security Number: ___ ___ ___ ___ Date of Birth:_____________________
(Month / Day / Year)
Age: ______
Sex:_________________
Ethnicity (Race):______________________
I hereby agree to answer all statements truthfully. The information provided on this SRS answer sheet is
true, correct, and accurate.
____________________________________________________
_____________________
Client Signature
Date
F
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
Section 2
Select the answer to each of the following statements that is accurate for you. Put an X under the number
(1, 2, 3, 4 or 5) that applies to you now.
86.
87.
88.
89.
90.
91.
92.
93.
94.
95.
96.
97.
98.
99.
100.
101.
102.
103.
1
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
2
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
3
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
4
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
5
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
104.
105.
106.
107.
108.
109.
110.
111.
112.
113.
114.
115.
116.
117.
118.
119.
120.
121.
1
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
2
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
3
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
4
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
5
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
Section 3
Put an X on your answer sheet under the number that you select for your answer. Use the following rating
scale.
1. Rare or Never
122.
123.
124.
125.
126.
127.
128.
129.
130.
131.
1
____
____
____
____
____
____
____
____
____
____
2. Sometimes
2
____
____
____
____
____
____
____
____
____
____
3
____
____
____
____
____
____
____
____
____
____
3. Often
4
____
____
____
____
____
____
____
____
____
____
132.
133.
134.
135.
136.
137.
138.
139.
140.
141.
142.
2
____
____
____
____
____
____
____
____
____
____
____
3
____
____
____
____
____
____
____
____
____
____
____
4
____
____
____
____
____
____
____
____
____
____
____
v72.414