<h2>Suicide Potential Survey</h2>
<strong>A. Nature of the suicide plan</strong>
<ol>
	<li>Vague idea &amp; no weapon</li>
	<li>A weak plan</li>
	<li>Some specific, realistic plan</li>
	<li>Complete plan with some details</li>
	<li> Complete plan with lethal details and weapon included</li>
</ol>
<strong>B. Prior attempts</strong>
<ol>
	<li>None, is only talking about it now</li>
	<li>Some past threats</li>
	<li>Numerous past ineffectual attempts</li>
	<li>None, but threatens lethal attempt now</li>
	<li>Has made lethal attempts in past</li>
</ol>
<strong>C. Mood</strong>
<ol>
	<li>Not healthy, but improves</li>
	<li>Controlled, matter of fact</li>
	<li>Partially controlled, but has bursts of extreme emotion</li>
	<li>Little control of mood, only moderate ups and downs</li>
	<li>Extreme depression, possibly with bursts of screams</li>
</ol>
<strong>D. Suicide weapon</strong>
<ol>
	<li>Mentions suicide, cannot explain how</li>
	<li>Specifies suicide but doesn’t have the means available</li>
	<li>Has barely adequate idea with the means available</li>
	<li>Wants to overdose, cut wrists, or inhale  gas and has the means</li>
	<li>Wants to shoot self, hang self, or jump and has the means at  hand</li>
</ol>
<strong>E. Contact with humanity</strong>
<ol>
	<li>Has family, friends&amp; job</li>
	<li>Has family and job, but no friends</li>
	<li>Has friends and job, but no family</li>
	<li>Has only family or friends for social contact</li>
	<li>Has no social contact</li>
</ol>
<strong>F. Age and sex</strong>
<ol>
	<li>Young woman</li>
	<li>Young man</li>
	<li>Middle age person</li>
	<li>Older woman</li>
	<li>Older man</li>
</ol>
<strong>G. Loss of a loved one</strong>
<ol>
	<li>No such loss incurred or  upcoming</li>
	<li>Possibility of such a loss</li>
	<li>Loved one has been lost, but doesn’t seem to be the chief concern</li>
	<li>Loss has occurred or will and you are upset</li>
	<li>Loss has taken place or will and you are very upset</li>
</ol>
<strong>H. Medical problems</strong>
<ol>
	<li>None</li>
	<li>General or vague physical complaints</li>
	<li>Serious physical symptoms,  hope for cure</li>
	<li>Serious medical symptoms, no hope for cure</li>
	<li>Older person, serious medical symptoms</li>
</ol>

<p>
Total points together that you circled and then divide by eight. This will give you your average score.  If the average score is 2 or higher, contact a mental health professional and discuss your problem with someone you can trust.  If your average score is 3.5 or higher, please contact us immediately.</p>