Today's Date* MM slash DD slash YYYY Client's Name* First Last Client's Date of Birth*MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920This field is hidden when viewing the formEmail Columbia-Suicide Severity Rating ScaleIn the past month, have you wished you were dead or wished you could go to sleep and not wake up?* Yes No In the past month, have you actually had any thoughts about killing yourself?* Yes No In the past month, have you thought about how you might do this?* Yes No In the past month, have you had any intention of acting on these thoughts of killing yourself? (As opposed to you have the thoughts, but you definitely would not act on them.)* Yes No In the past month, have you started to work out, or actually worked out, the specific details of how to kill yourself and did you intend to carry out your plan?* Yes No In your lifetime, have you done anything, started to do anything, or prepared to do anything to end your life?* Yes No In the past 3 months, have you done any of the following?*• Attempted to kill yourself even if ending your life was only part of your motivation • Started to do something to end your life but someone or something stopped you before you actually did anything • Started to do something to end your life but you stopped yourself before you actually did anything • Taken any steps towards making a suicide attempt or preparing to kill yourself Examples: Collected pills, obtained a gun, gave away valuables, wrote a will or suicide note, took out pills but didn't swallow any, held a gun but changed your mind or it was grabbed from your hand, wend to the roof but didn't jump; or actually took pills, tried to shoot yourself, tried to hang yourself, etc. Yes No What did you do?*
