HHC-Suicide Risk Assessment & Intervention
All questions with an * are required
Who is Calling
When was the Call?
Name
First Name
Last Name
Gender
*
Male
Female
Other
Contact Number
*
Dzongkhag Gewog
Place
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Time
*
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
What is the Caller ringing For?
How can I help?
Third Party Caller
*
Yes, calling about immediate family member
Yes, calling about relative
Yes, calling about friend
Yes, calling about a stranger
No
Third Party Caller Intervention
What has been happening for the caller recently? What has prompted them to call?
*
Conflict in relationship with family member
Conflict in relationship with partner or friend
Death of a relative, partner or friend
Martial separation or divorce
Pregnancy
Physical problem/illness
Financial problem
Abuse/domestic violence
Problems with police or legal system
School-related problem
Work-related problem
Religious belief
Cultural issue
Unknown
Other
Presence Suicidal Ideation/Plan
*
Nil
Wished they were dead
Believed family would be better off without them
Thoughts of taking life
Tried to end their life
Plan to take life
Access to means
Intent to enact plan
Previous attempt
Diagnosed Psychological Disorder
Anxiety
Depression
Bipolar Disorder
Dementia
Schizophrenia or Psychosis
Stress related including PTSD
Substance Use Disorder
No
Unknown
Caller Intoxicated
*
Yes
No
Unknown
Risk and Intervention
Caller Assessed Risk
*
Low
Moderate
High
Low Risk Intervention
Safety Plan Discussed
Referral to Support Agency
Other
Moderate Risk Intervention
Safety Plan Developed
Next of Kin Informed
Referral to Support Agency
Other
High Risk Intervention
Safety Activities Discussed
Ambulance Dispatched
Next of Kin Informed
Nearest Health Centre informed
Brief description of intervention
Approximate Length of Call
*
minutes
Call Taken By
First Name
Last Name
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Is there any educational material that would have helped as a responder to this call?
Demographics
As much information as the caller provided
Nationality of Caller
Bhutanese
Indian
Other
Approximate Age
*
Under 18
18 - 24
25 - 40
41 - 59
Over 60
Next of Kin Name
Next of Kin Contact Number
Marital Status
Single
Living Together
Married
Divorced
Widowed
Unknown
Occupation
Civil Service
Armed Forces/RBP
Monastic/lay-monk
Labourers
Farming
Private Companies/Businesses
Corporate
Student
Housewife
Unemployed
Other
Unknown/Did not say
Other
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If you would like a debrief from a supervisor, please record your name and contact number
Someone will be in contact within the next 24 hours
Name
First Name
Last Name
Phone Contact
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Follow Up
within 3 days of call
Date Follow-Up Completed
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Outcome
No answer/phone switched off
Caller engaged with support service
Improved mood
Current suicidal ideation
Brief Description of Call
Follow-Up Completed By
First Name
Last Name
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