Self Harm Form (copline) Copline Suicide Assessment Form Patient Name First Last Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PhoneDirections: The best Evidence shows that assessing lethality is best completed with a face to face interview and a Suicide/Self/Harm Assessment tool. Please complete box sections below: Directions: Answer Section I Complete Section II by checking one of the three descriptions for each Key factor that BEST describes the patient Complete Section III Add the points for each checked item in section I, II, III to obtain the total score Section IIs the current interaction precipitated by suicide attempt? Yes = 2 No = 1 HiddenSection I – "No"HiddenSection I – "Yes"Section I Total ScoreSection II – Key FactorsRisk Factors legal problems serious mental illness hopelessness financial difficulties physical illness physical/sexual abuse impulsivity age psychological stresses lives alone family history assaultive history substance abuse guilt sex recent loss no support # of Risk FactorsHiddenLow Risk HiddenModerate Risk HiddenHigh Risk HiddenRisk Factor Score High Risk (+2) Level 1 5-6 risk factors present Moderate Risk (+1) Level 2 3-4 risk factors present Low Risk (+0) Level 3/no precaution 0-2 risk factors present Suicide PlanChoose OptionHas plan with actual or potential access to planned method = 2Has plan without actual or potential access to planned method = 1No Plan = 0Plan LethalityChoose OptionHigh lethality plan (gun, hanging, jumping, carbon monoxide) = 2Medium lethality plan (sleeping pills, overdose) = 1Low lethality of plan (superficial scratching, head banging, pillow over face, holding breath) = 0Elopement RiskChoose OptionHigh elopement risk = 2Low elopement risk = 1No elopement risk = 0Suicidal IdeationChoose OptionConstant suicidal thoughts = 2Intermittent suicidal thoughts = 1No current suicidal thoughts = 0Attempt HistoryChoose OptionPast attempts of high lethality = 2Past attempts of low lethality = 1No previous attempts = 0Symptoms hopelessness helplessness anhedonia guilt/shame anger/hostility impulsivity impaired problem solving Number of Symptoms PresentHidden5-6 SymptomsHidden3-4 SymptomsHidden0-2 SymptomsHiddenSymptom Score 5-6 symptoms present (+2) 3-4 symptoms present (+1) 0-2 symptoms present (+0) Current Morbid Thoughts(reunion fantasies, preoccupation with death, disturbing nightmares)Choose OptionConstantly = 2Frequently = 1Rarely = 0Section II TotalSection IIIRN/Counselor's Subjective appraisal of patient's reliabilityChoose OptionPatient's replies are not trustworthy = 2Patient's replies are questionable = 1Patient's replies are trustworthy = 0Section III TotalIV. ScoringPoints ScoredSection I + Section II + Section III
