A. Nature of the suicide plan .....................................E. Contact with humanity
1. Vague idea & no weapon 1. Has family, friends& job
2. A weak plan 2. Has family and job, but no friends
3. Some specific, realistic plan 3. Has friends and job, but no family
4. Complete plan with some details 4. Has only family or friends for social
5. Complete plan with lethal details contact
and weapon included 5. Has no social contact
B. Prior attempts.......................................................F. Age and sex
1. None, is only talking about it now 1. Young woman
2. Some past threats 2. Young man
3. Numerous past ineffectual attempts 3. Middle age person
4. None, but threatens lethal attempt now 4. Older woman
5. Has made lethal attempts in past 5. Older man
C. Mood...................................................................G. Loss of a loved one
1. Not healthy, but improves 1. No such loss incurred or upcoming
2. Controlled, matter of fact 2. Possibility of such a loss
3. Partially controlled, but has bursts of 3. Loved one has been lost, but doesn’t
extreme emotion seem to be the chief concern
4. Little control of mood, only moderate ups 4. Loss has occurred or will and you are
and downs upset
5. Extreme depression, possibly with bursts 5. Loss has taken place or will and you
of screams are very upset and an alcoholic
D. Suicide weapon.....................................................H. Medical problems
1. Mentions suicide, cannot explain how 1. None
2. Specifies suicide but doesn’t have the 2. General or vague physical complaints
means available 3. Serious physical symptoms, hope for cure
3. Has barely adequate idea with the means 4. Serious medical symptoms, no hope for
available cure
4. Wants to overdose, cut wrists, or inhale gas 5. Older person, serious medical symptoms
and has the means
5. Wants to shoot self, hang self, or jump and
has the means at hand
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.
