CAMS SUICIDE STATUS FORM 4 (SSF-4) INITIAL SESSION Patient: Clinician: Date: Time: Section A (Patient):
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1 CAMS SUICIDE STATUS FORM 4 (SSF-4) INITIAL SESSION Patient: Clinician: Date: Time: Section A (Patient): Rank Rate and fill out each item according to how you feel right now. Then rank in order of importance 1 to 5 (1 = most important to 5 = least important) 1) RATE PSYCHOLOGICAL PAIN (hurt, anguish, or misery in your mind, not stress, not physical pain): Low pain: :High pain What I find most painful is: 2) RATE STRESS (your general feeling of being pressured or overwhelmed): Low stress: :High stress What I find most stressful is: 3) RATE AGITATION (emotional urgency; feeling that you need to take action; not irritation; not annoyance): Low agitation: :High agitation I most need to take action when: 4) RATE HOPELESSNESS (your expectation that things will not get better no matter what you do): Low hopelessness: :High hopelessness I am most hopeless about: 5) RATE SELF-HATE (your general feeling of disliking yourself; having no self-esteem; having no self-respect): Low self-hate: :High self-hate What I hate most about myself is: N/A 6) RATE OVERALL RISK Extremely low risk: :Extremely high risk OF SUICIDE: (will not kill self) (will kill self) 1) How much is being suicidal related to thoughts and feelings about yourself? Not at all: : completely 2) How much is being suicidal related to thoughts and feeling about others? Not at all: : completely Please list your reasons for wanting to live and your reasons for wanting to die. Then rank in order of importance 1 to 5. Rank REASONS FOR LIVING Rank REASONS FOR DYING I wish to live to the following extent: Not at all: : Very much I wish to die to the following extent: Not at all: : Very much The one thing that would help me no longer feel suicidal would be:
2 Section B (Clinician): Y N Suicide ideation Frequency per day per week per month Duration seconds minutes hours Y N Suicide plan Y N Suicide preparation Y N Suicide rehearsal When: Where: How: How: Y N History of suicidal behaviors Single attempt Multiple attempts Y N Impulsivity Y N Substance abuse Y N Significant loss Y N Relationship problems Y N Burden to others Y N Health/pain problems Y N Sleep problems Y N Legal/financial issues Y N Shame Access to means Y N Access to means Y N Section C (Clinician): TREATMENT PLAN Problem # 1 Problem Description Goals and Objectives Interventions Self-Harm Potential Safety and Stability Stabilization Plan Completed Duration 2 3 YES NO Patient understands and concurs with treatment plan? YES NO Patient at imminent danger of suicide (hospitalization indicated)? Patient Signature Date Clinican Signature Date
3 CAMS STABILIZATION PLAN Ways to reduce access to lethal means: Things I can do to cope differently when I am in a suicide crisis (consider crisis card): Life or death emergency contact number: People I can call for help or to decrease my isolation: Attending treatment as scheduled: Potential barrier: Solutions I will try: 1. 2.
4 Section D (Clinician Postsession Evaluation): MENTAL STATUS EXAM (Circle appropriate items): ALERTNESS: ALERT DROWSY LETHARGIC STUPOROUS ORIENTED TO: PERSON PLACE TIME REASON FOR EVALUATION MOOD: EUTHYMIC ELEVATED DYSPHORIC AGITATED ANGRY AFFECT: FLAT BLUNTED CONSTRICTED APPROPRIATE LABILE THOUGHT CONTINUITY: CLEAR & COHERENT GOAL-DIRECTED TANGENTIAL CIRCUMSTANTIAL THOUGHT CONTENT: WNL OBSESSIONS DELUSIONS IDEAS OF REFERENCE BIZARRENESS MORBIDITY ABSTRACTION: WNL NOTABLY CONCRETE SPEECH: WNL RAPID SLOW SLURRED IMPOVERISHED INCOHERENT MEMORY: GROSSLY INTACT REALITY TESTING: WNL NOTABLE BEHAVIORAL OBSERVATIONS: DIAGNOSTIC IMPRESSIONS/DIAGNOSIS (DSM/ICD DIAGNOSES): PATIENT S OVERALL SUICIDE RISK LEVEL (Check one and explain): LOW (WTL/RFL) Explanation: MODERATE (AMB) HIGH (WTD/RFD) CASE NOTES: Next Appointment Scheduled: Treatment Modality: Clinican Signature Date
5 CAMS SUICIDE STATUS FORM 4 (SSF-4) TRACKING/UPDATE INTERIM SESSION Patient: Clinician: Date: Time: Section A (Patient): Rate and fill out each item according to how you feel right now. 1) RATE PSYCHOLOGICAL PAIN (hurt, anguish, or misery in your mind, not stress, not physical pain): Low pain: :High pain 2) RATE STRESS (your general feeling of being pressured or overwhelmed): Low stress: :High stress 3) RATE AGITATION (emotional urgency; feeling that you need to take action; not irritation; not annoyance): Low agitation: :High agitation 4) RATE HOPELESSNESS (your expectation that things will not get better no matter what you do): Low hopelessness: :High hopelessness 5) RATE SELF-HATE (your general feeling of disliking yourself; having no self-esteem; having no self-respect): Low self-hate: :High self-hate 6) RATE OVERALL RISK Extremely low risk: :Extremely high risk OF SUICIDE: (will not kill self) (will kill self) In the past week: Suicidal Thoughts/Feelings Y N Managed Thoughts/Feelings Y N Suicidal Behavior Y N Section B (Clinician): Patient Status: Discontinued treatment No show Resolution of suicidality, if: current overall risk of suicide < 3; in past week: no suicidal behavior and effectively managed suicidal thoughts/feelings 1st session 2nd session **Complete SSF Outcome Form at 3rd consecutive resolution session** TREATMENT PLAN UPDATE Cancelled Hospitalization Referred/Other: Problem # 1 Problem Description Goals and Objectives Interventions Self-Harm Potential Safety and Stability Stabilization Plan Completed Duration 2 3 Patient Signature Date Clinican Signature Date
6 Section C (Clinician Postsession Evaluation): MENTAL STATUS EXAM (Circle appropriate items): ALERTNESS: ALERT DROWSY LETHARGIC STUPOROUS ORIENTED TO: PERSON PLACE TIME REASON FOR EVALUATION MOOD: EUTHYMIC ELEVATED DYSPHORIC AGITATED ANGRY AFFECT: FLAT BLUNTED CONSTRICTED APPROPRIATE LABILE THOUGHT CONTINUITY: CLEAR & COHERENT GOAL-DIRECTED TANGENTIAL CIRCUMSTANTIAL THOUGHT CONTENT: WNL OBSESSIONS DELUSIONS IDEAS OF REFERENCE BIZARRENESS MORBIDITY ABSTRACTION: WNL NOTABLY CONCRETE SPEECH: WNL RAPID SLOW SLURRED IMPOVERISHED INCOHERENT MEMORY: GROSSLY INTACT REALITY TESTING: WNL NOTABLE BEHAVIORAL OBSERVATIONS: DIAGNOSTIC IMPRESSIONS/DIAGNOSIS (DSM/ICD DIAGNOSES): PATIENT S OVERALL SUICIDE RISK LEVEL (Check one and explain): MILD (WTL/RFL) Explanation: MODERATE (AMB) HIGH (WTD/RFD) CASE NOTES: Next Appointment Scheduled: Treatment Modality: Clinican Signature Date
7 CAMS SUICIDE STATUS FORM 4 (SSF-4) OUTCOME/DISPOSITION FINAL SESSION Patient: Clinician: Date: Time: Section A (Patient): Rate and fill out each item according to how you feel right now. 1) RATE PSYCHOLOGICAL PAIN (hurt, anguish, or misery in your mind, not stress, not physical pain): Low pain: :High pain 2) RATE STRESS (your general feeling of being pressured or overwhelmed): Low stress: :High stress 3) RATE AGITATION (emotional urgency; feeling that you need to take action; not irritation; not annoyance): Low agitation: :High agitation 4) RATE HOPELESSNESS (your expectation that things will not get better no matter what you do): Low hopelessness: :High hopelessness 5) RATE SELF-HATE (your general feeling of disliking yourself; having no self-esteem; having no self-respect): Low self-hate: :High self-hate 6) RATE OVERALL RISK Extremely low risk: :Extremely high risk OF SUICIDE: (will not kill self) (will kill self) In the past week: Suicidal Thoughts/Feelings Y N Managed Thoughts/Feelings Y N Suicidal Behavior Y N Where there any aspects of your treatment that were particularly helpful to you? If so, please describe these. Be as specific as possible. What have you learned from your clinical care that could help you if you became suicidal in the future? Section B (Clinician): Third consecutive session of resolved suicidality: Yes No (If no, continue CAMS tracking) **Resolution of suicidality, if for third consecutive week: current overall risk of suicide < 3; in past week: no suicidal behavior and effectively managed suicidal thoughts/feelings OUTCOME/DISPOSITION (Check all that apply): Continuing outpatient psychotherapy Mutual termination Referral to: Other. Next Appointment Scheduled (if applicable): Inpatient hospitalization Patient chooses to discontinue treatment (unilaterally) Patient Signature Date Clinican Signature Date
8 Section C (Clinician Postsession Evaluation): MENTAL STATUS EXAM (Circle appropriate items): ALERTNESS: ALERT DROWSY LETHARGIC STUPOROUS ORIENTED TO: PERSON PLACE TIME REASON FOR EVALUATION MOOD: EUTHYMIC ELEVATED DYSPHORIC AGITATED ANGRY AFFECT: FLAT BLUNTED CONSTRICTED APPROPRIATE LABILE THOUGHT CONTINUITY: CLEAR & COHERENT GOAL-DIRECTED TANGENTIAL CIRCUMSTANTIAL THOUGHT CONTENT: WNL OBSESSIONS DELUSIONS IDEAS OF REFERENCE BIZARRENESS MORBIDITY ABSTRACTION: WNL NOTABLY CONCRETE SPEECH: WNL RAPID SLOW SLURRED IMPOVERISHED INCOHERENT MEMORY: GROSSLY INTACT REALITY TESTING: WNL NOTABLE BEHAVIORAL OBSERVATIONS: DIAGNOSTIC IMPRESSIONS/DIAGNOSIS (DSM/ICD DIAGNOSES): PATIENT S OVERALL SUICIDE RISK LEVEL (Check one and explain): LOW (WTL/RFL) Explanation: MODERATE (AMB) HIGH (WTD/RFD) CASE NOTES: Clinican Signature Date
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