Date: [Date of encounter]
Client: [Client Name]
Presenting Concerns: This section should summarize the client’s current suicidal thoughts and feelings.
Include details about the frequency, intensity, and duration of suicidal ideation.
Note any specific plans or methods the client has considered.
Risk Assessment:
Suicidal Intent: Assess the client’s intent to act on suicidal thoughts.
Consider factors like hopelessness, desperation, and access to means.
Risk Factors: Identify any underlying conditions or situations that increase suicide risk.
Examples include mental health diagnoses, substance abuse, past suicide attempts, and social isolation.
Protective Factors: Identify any strengths or supports that can help mitigate suicide risk.
Examples include strong social connections, coping skills, and access to mental health care.
Intervention:
Describe the interventions used to address the client’s suicidal ideation.
This may include exploring the reasons behind the ideation, developing coping skills, and creating a safety plan.
Safety Plan: Outline the specific steps the client will take if they experience suicidal thoughts again.
Include reaching out to crisis support resources, trusted individuals, or mental health professionals.
Referral: If needed, document any referrals made to other mental health professionals or crisis support services.
Response:
Summarize the client’s response to the interventions.
Did they seem receptive to the safety plan? Are they willing to engage in further treatment?
Prognosis:
Briefly assess the client’s current risk of suicide.
Has the ideation lessened in intensity or frequency?
Indicate the need for continued monitoring and follow-up.
Next Steps:
Outline the next steps in the client’s treatment plan.
This may include scheduling follow-up appointments, medication adjustments, or additional support services.
Additional Notes:
Include any other relevant information not covered in the above sections.
Important Note: This is a template and should be adapted to fit the specific needs of each client. It is crucial to follow all applicable HIPAA regulations when documenting suicidal ideation.