Date*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Name* First Last Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Email 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?*YesNoIn the past month, have you actually had any thoughts about killing yourself?*YesNoHave you thought about how you might do this?*YesNoHave you started to work out or worked out the details of how to kill yourself?*YesNoDo you intend to carry out this plan?*YesNoIn 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.YesNoIn your entire lifetime, how many times have you done any of these things?*
