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Bereavement
Crisis
Sanctuary
- Post Contact Survey
General

Risk Management Plan – Bereavement

Risk Management Plan - Bereavement

Current risk to self

Have you ever thought of taking your life, even though you would not actually do it?

Yes No

If yes, could you give the date(s) or approximate?

Have you ever tried to end your life previously?

Yes No

Was this an attempt to take your life, by taking an overdose of tablets or in some other way?

Yes No

If yes, could you give the date(s) or approximate?

How did you try to do this?

Were you alone when you made the attempt?

Yes No

Where were you?

Did you tell anyone before?

Yes No

How were you feeling before the attempt?

UPPS

I have trouble controlling my impulses

Definitely Agree Slightly Agree Slightly Disagree Definitely Disagree

I have trouble resisting my cravings (for food, cigarettes etc)

Definitely Agree Slightly Agree Slightly Disagree Definitely Disagree

I often get involved in things I later wish I could get out of

Definitely Agree Slightly Agree Slightly Disagree Definitely Disagree

When I feel bad, I will often do things I later regret in order to make myself feel better now

Definitely Agree Slightly Agree Slightly Disagree Definitely Disagree

Sometimes when I feel bad, I can’t seem to stop what I am doing even though it is making me feel worse

Definitely Agree Slightly Agree Slightly Disagree Definitely Disagree

When I am upset, I often act without thinking

Definitely Agree Slightly Agree Slightly Disagree Definitely Disagree

When I feel rejected, I will often say things I later regret

Definitely Agree Slightly Agree Slightly Disagree Definitely Disagree

It is hard for me to resist acting on my feelings

Definitely Agree Slightly Agree Slightly Disagree Definitely Disagree

I often make matters worse because I act without thinking when I am upset

Definitely Agree Slightly Agree Slightly Disagree Definitely Disagree

In the head of an argument, I will often say things that I later regret

Definitely Agree Slightly Agree Slightly Disagree Definitely Disagree

I always keep my feelings under control

Definitely Agree Slightly Agree Slightly Disagree Definitely Disagree

Sometimes I do impulsive things I later regret

Definitely Agree Slightly Agree Slightly Disagree Definitely Disagree

Present suicidal thoughts

Do you have suicidal thoughts presently?

Yes No

Frequency (how often)?

Intensity (on a scale 0 – 10 with 10 being the most of)

1 2 3 4 5 6 7 8 9 10

Duration (duration of intensity)

Planning (have you made a plan can you tell me about this)

Accessibility to social support?

Yes No

Record details (who are clients support systems)

Main support:

Relationship

Name

Address

Telephone Number

2nd Support:

Relationship

Name

Address

Telephone Number

3rd Support:

Relationship

Name

Address

Telephone Number

4th Support:

Relationship

Name

Address

Telephone Number

Risk to others

Has anyone else been worried about your behaviour recently?

Yes No

Over the last week: Have you been physically violent to others?

Yes No

Have you threatened or intimidated another person?

Yes No

Risk to Children or vulnerable Adults

How do your current difficulties impact on the way you care for others?