QPRT- Pediatric Re-evaluation of Suicide Risk- Inpatient

Client’s Name: Case Number: Date: Time:

Reason for Re-evaluation:
Questioned the client about thoughts of suicide? Yes No (If no, explain why in attached note.)
Suicidal thoughts, feelings, and/or behaviors present? Yes No
If yes, can you tell me what you’re upset about?
If yes,do you know how you would hurt/kill yourself now? With what/when/where? (Explore all)
If yes, what level of control do you feel?
What is different in your life since the last time we met? How has this affected you?
What are the current challenges in your life?How are you coping?
Who else knows? Who may be able to help you?
What are some reasons you have for living?
Changes in suicide risk factors:
1. Assess current status of previous risk factors
2. Indicate new factors / Wish to die
Access to means
Past suicide attempts
Hopelessness
Perceived burdensomeness
High-risk diagnosis
Agitation/Anxiety
Command hallucinations
Emotionally upset
Labile mood / Abuse history
Feeling deeply alone
Impulsive/Aggressive
Perfectionism
Sleep disturbance
Culture shock
Family problems
Perceived traumatic loss
School problems
Fearlessness about suicide / Demanding/Assaultive/Complaining
Cognitive distortions
Difficulty concentrating
Serious health problem
Drug/Alcohol abuse
Family history of suicidal behavior
History of violence to self and others
Unwilling/Unable to commit to safety
Other (explain)
Changes in protective factors:
1. Assess current status of previous protective factors
2. Indicate new factors / Has a job
Responsibility for children
Duty to others
Good grades in school
School connectedness
Extracurricular involvement
Supportive other / Medication compliance
Fear of death/pain
Sobriety
Difficult access to means
A sense of hope
Good health
Positive self-esteem / Pets
Religious prohibition
Calm environment
Best friend(s)
Safety agreement
Engaged in treatment
Other (explain)
Safety Agreement
Client agrees to: (check all that apply)
To not hurt or kill self accidentally or on purpose
To notify staff of urge to harm/kill self
To agree to share in development and implementation of a treatment plan
Other:
OR
Unwilling/Unable to commit to safety
Client’s statement of agreement to safety (verbatim):
Client Signature:______Date/Time:______
If no signature, explanation:
Assessor: ______Signature:______Date/Time: ______
Level of Risk / Check
box / Risk Management Plan
High /
  1. Line of sight supervision
  2. Psychiatric consult
  3. Means restriction (specify)
  4. Re-evaluation of risk at each session

Moderate /
  1. Increased supervision
  2. Clinical team consultation
  3. Means restriction (specify)
  4. Periodic re-evaluation

Low /
  1. Routine monitoring
  2. Routine means restriction
  3. Re-evaluation according to QPRT procedures
  4. Discuss low-risk status with clinical team

No Known Risk /
  1. Routine monitoring
  2. Routine means restriction
  3. Re-evaluation according to QPRT procedures
  4. Discuss no known risk status with clinical team

Other precautions/interventions:
Justification for risk level (risk/benefit analysis):
Physician/Team discussions or additional comments:

If client is assessed to be at low or no known risk only, review this section for accuracy and initial here ______. “Client denies desire to

hurt or kill himself or herself, and there are no substantial suicide risk factors present. The client is oriented to person, time, and place, sober,

non-psychotic, attentive, and cooperative. The client and/or caregiver were advised to inform me or should this

change. The client and/or caregiver were assessed to have the capacity to assess the risk and benefits of treatment and/or recommendations

for same, and know(s) what to do in the event of worsening distress and the need to seek additional help.”

Assessor: ______Signature: ______Title: ______Date/Time: ______

QPRT-Pediatric

Re-evaluation of Suicide Risk- Inpatient

© Lou Sowers, Ph.D., Paul Quinnett, Ph.D., and Kevin Bratcher, M.S., 1999