Name _______________________________ Date Instructions: Check the number beside the statement that best applies to you. - Have you ever thought about or attempted to kill yourself? (check one only)
- _______ 1. Never.
- _______ 2. It was just a brief passing thought.
- _______ 3a. I have had a plan at least once to kill myself but did not try to do it.
- _______ 3b. I have had a plan at least once and really wanted to die.
- _______ 4a. I have attempted to kill myself, but did not want to die.
- _______ 4b. I have attempted to kill myself and really hoped to die.
- How often have you thought about killing yourself in the past? (check one only)
- _______ 1. Never.
- _______ 2. Rarely (1 time).
- _______ 3. Sometimes (2 times).
- _______ 4. Often (3–4 times).
- _______ 5. Very Often (5 or more times).
- Have you ever told someone that you were going to commit suicide, or that you might do it? (check one only)
- _______ 1. No.
- _______ 2a. Yes, at one time, but did not really want to die.
- _______ 2b. Yes, at one time and really wanted to die.
- _______ 3a. Yes, more than once, but did not want to do it.
- _______ 3b. Yes, more than once and really wanted to do it.
- How likely is it you will attempt suicide someday? (check one only)
- _______ 0. Never
- _______ 1. No chance at all
- _______ 2. Rather unlikely
- _______ 3. Unlikely
- _______ 4. Likely
- _______ 5. Rather likely
- _______ 6. Very likely
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