Week3AssignmentTemplate.docx

Student Name:
Week 4 Assignment Template
Part 1 – Suicide Risk Assessment and Intervention
Scenario A, Sal

Desire

☐Suicidal/violent ideation ☐Psychological pain ☐Hopelessness ☐Helplessness
☐Perceived burden on others ☐Feeling trapped ☐Feeling intolerably alone

Notes:

Capability

☐History of suicide attempts ☐Exposure to suicide or violence in the past ☐Extreme agitation or rage
☐History of/current self-harm or violence toward others ☐Availability of means
☐Substance abuse ☐Currently intoxicated ☐Sleep deprivation ☐Acute symptoms of mental illness

Notes:

Intent

☐Attempt in progress ☐Preparatory behavior ☐Client expressed intent
☐Client has a plan (time and/or method) Always ask the client directly whether they have a plan

Notes:

Buffers/Connectedness

☐Immediate supports ☐Social supports ☐Planning for the future
☐Engagement with crisis worker ☐Core values/beliefs ☐Sense of purpose
☐Client verbalizes reasons for living/no violence ☐Client acknowledges ambivalence

Notes:

Risk level

☐Low Risk (desire only)
☐Low-Moderate Risk (desire + capability + numerous buffers)
☐Moderate Risk (desire + capability)
☐Moderate-High Risk (desire + capability + intent + numerous buffers)
☐High Risk (desire + capability + intent)

Plan of Action

· The Plan of Action should be as detailed as possible and driven by the client.
· The checkboxes below are to guide you. You should detail each step in the numbered section.
☐Self-care (specify) ☐Referrals ☐Medication evaluation ☐Removal of means
☐Involve family or other social supports ☐Verbal no-suicide/violence agreement
☐Hospitalization ☐Follow-up with counselor within 48 hours ☐Other (specify)

1.
2.
3.

Add more steps if needed

Scenario B, Maria

Desire

☐Suicidal/violent ideation ☐Psychological pain ☐Hopelessness ☐Helplessness
☐Perceived burden on others ☐Feeling trapped ☐Feeling intolerably alone

Notes:

Capability

☐History of suicide attempts ☐Exposure to suicide or violence in the past ☐Extreme agitation or rage
☐History of/current self-harm or violence toward others ☐Availability of means
☐Substance abuse ☐Currently intoxicated ☐Sleep deprivation ☐Acute symptoms of mental illness

Notes:

Intent

☐Attempt in progress ☐Preparatory behavior ☐Client expressed intent
☐Client has a plan (time and/or method) Always ask the client directly whether they have a plan

Notes:

Buffers/Connectedness

☐Immediate supports ☐Social supports ☐Planning for the future
☐Engagement with crisis worker ☐Core values/beliefs ☐Sense of purpose
☐Client verbalizes reasons for living/no violence ☐Client acknowledges ambivalence

Notes:

Risk level

☐Low Risk (desire only)
☐Low-Moderate Risk (desire + capability + numerous buffers)
☐Moderate Risk (desire + capability)
☐Moderate-High Risk (desire + capability + intent + numerous buffers)
☐High Risk (desire + capability + intent)

Plan of Action

· The Plan of Action should be as detailed as possible and driven by the client.
· The checkboxes below are to guide you. You should detail each step in the numbered section.
☐Self-care (specify) ☐Referrals ☐Medication evaluation ☐Removal of means
☐Involve family or other social supports ☐Verbal no-suicide/violence agreement
☐Hospitalization ☐Follow-up with counselor within 48 hours ☐Other (specify)

1.
2.
3.

Add more steps if needed

Scenario C, Beth

Desire

☐Suicidal/violent ideation ☐Psychological pain ☐Hopelessness ☐Helplessness
☐Perceived burden on others ☐Feeling trapped ☐Feeling intolerably alone

Notes:

Capability

☐History of suicide attempts ☐Exposure to suicide or violence in the past ☐Extreme agitation or rage
☐History of/current self-harm or violence toward others ☐Availability of means
☐Substance abuse ☐Currently intoxicated ☐Sleep deprivation ☐Acute symptoms of mental illness

Notes:

Intent

☐Attempt in progress ☐Preparatory behavior ☐Client expressed intent
☐Client has a plan (time and/or method) Always ask the client directly whether they have a plan

Notes:

Buffers/Connectedness

☐Immediate supports ☐Social supports ☐Planning for the future
☐Engagement with crisis worker ☐Core values/beliefs ☐Sense of purpose
☐Client verbalizes reasons for living/no violence ☐Client acknowledges ambivalence

Notes:

Risk level

☐Low Risk (desire only)
☐Low-Moderate Risk (desire + capability + numerous buffers)
☐Moderate Risk (desire + capability)
☐Moderate-High Risk (desire + capability + intent + numerous buffers)
☐High Risk (desire + capability + intent)

Plan of Action

· The Plan of Action should be as detailed as possible and driven by the client.
· The checkboxes below are to guide you. You should detail each step in the numbered section.
☐Self-care (specify) ☐Referrals ☐Medication evaluation ☐Removal of means
☐Involve family or other social supports ☐Verbal no-suicide/violence agreement
☐Hospitalization ☐Follow-up with counselor within 48 hours ☐Other (specify)

1.
2.
3.

Add more steps if needed

Part 2 – Violence Risk Assessment and Intervention

What risk factors did Jake have for violence?

What did you think the counselor did well?

What would you do differently? (you cannot answer that you would not change anything.)