Take The Survey

Suicide Potential Survey

A. Nature of the suicide plan

  1. Vague idea & no weapon
  2. A weak plan
  3. Some specific, realistic plan
  4. Complete plan with some details
  5. Complete plan with lethal details and weapon included

B. Prior attempts

  1. None, is only talking about it now
  2. Some past threats
  3. Numerous past ineffectual attempts
  4. None, but threatens lethal attempt now
  5. Has made lethal attempts in past

C. Mood

  1. Not healthy, but improves
  2. Controlled, matter of fact
  3. Partially controlled, but has bursts of extreme emotion
  4. Little control of mood, only moderate ups and downs
  5. Extreme depression, possibly with bursts of screams

D. Suicide weapon

  1. Mentions suicide, cannot explain how
  2. Specifies suicide but doesn’t have the means available
  3. Has barely adequate idea with the means available
  4. Wants to overdose, cut wrists, or inhale gas and has the means
  5. Wants to shoot self, hang self, or jump and has the means at hand

E. Contact with humanity

  1. Has family, friends& job
  2. Has family and job, but no friends
  3. Has friends and job, but no family
  4. Has only family or friends for social contact
  5. Has no social contact

F. Age and sex

  1. Young woman
  2. Young man
  3. Middle age person
  4. Older woman
  5. Older man

G. Loss of a loved one

  1. No such loss incurred or upcoming
  2. Possibility of such a loss
  3. Loved one has been lost, but doesn’t seem to be the chief concern
  4. Loss has occurred or will and you are upset
  5. Loss has taken place or will and you are very upset

H. Medical problems

  1. None
  2. General or vague physical complaints
  3. Serious physical symptoms, hope for cure
  4. Serious medical symptoms, no hope for cure
  5. Older person, serious medical symptoms

Total points together that you circled and then divide by eight. This will give you your average score. If the average score is 2 or higher, contact a mental health professional and discuss your problem with someone you can trust. If your average score is 3.5 or higher, please contact us immediately.