Form05 - [FORM 5-Use the top of this page for your...

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[ FORM 5 —Use the top of this page for your letterhead.] Checklist of Suicide Risk Factors Client: Date: The following ratings are based on my: q Review of records (specify): q Interview with staff, friends, relatives (circle and name): q Observations of this individual over the last q interview q day q week q month q Other (specify): Demographic risk factors q European American or Native American q Male q Protestant q Lowest socioeconomic class q Suicidal partner q Never-married or widowed status q Divorced status (especially repeated divorce or divorce in last 6 months) q Age: Young adult (15–24) or very elderly (75–85 or older) Historical risk factors q Relative or close friend died by suicide q Criminal behaviors q Poor work history q Checked “suicide” on intake form or other assessments q Self-mutilating behaviors q History of substance abuse or dependence q History of abuse (physical, sexual, of long duration, etc.) q Suicidal behaviors: q Multiple threats/attempts of q high lethality q high violence q
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Form05 - [FORM 5-Use the top of this page for your...

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