Suicide Risk Questionnaire

Part 1.

a) Have you heard...?

Life isn't worth living

My family would be better off without me

Next time I'll take enough pills to do the job right

Take my (prized collection, valuables) I don't need this stuff anymore

I won't be around to deal with that

I won't be in your way much longer

I just can't deal with everything, life's too hard

Nobody understands me, nobody feels the way I do

There's nothing I can do to make it better

I'd be better off dead

b) Have you observed...?

Getting affairs in order, such as paying of debts or changing will

Giving away articles or either personal or monetary value

Signs of planning a suicide, such as obtaining a weapon or writing a suicide note

 

Part 11. Depression Risk Questionnaire

a) Have you noticed the following signs of depression?

Depressed mood

Change in sleeping patterns (too much too little or disturbances)

Change in weight or appetite

Speaking and/or moving with unusual speed or slowness

Loss of interest or pleasure in usual activities

Withdrawal from family and friends

Fatigue or loss of energy

Feelings of worthlessness, self reproach or guilt

Diminished ability to think or concentrate, slowed thinking or indecisiveness

Thoughts of death, suicide or wishes to be dead

b) If depression is possible have you also noticed...?

Extreme anxiety, agitation, or enraged behavior

Excessive drug and/or alcohol abuse

Neglect of physical health

Feelings of hopelessness or desperation

 

HOW TO INTERPRET QUESTIONNAIRE

If you checked boxes under....

  • Part 1 only, then your friend may be at risk for suicide and should seek professional help immediately
  • Part 11 only, then your friend may be suffering from depression and should seek further evaluation with a mental health professional or his primary care physician
  • Parts 1 and 11, the suicide risk is even higher for your friend. Strongly encourage your friend to seek professional help immediately

RESOURCES FOR MORE HELP

 

 

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