Deliberate self-harm and Mental Health assessment form
This form is designed to help an assessor consider the risk to the patient of self-harm or suicide and risk of
harm to staff members. Risk assessment requires clinical judgement which may override this form in some
circumstances.
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Persons should be seen on their own unless they object. You should try and persuade others
to leave. If an adolescent, give the family a chance to speak later on. Ask the patient if they
can be seen separately or with parents or others.
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DSH Method if relevant:
Drugs 
Cuts 
Other

Gas 
Hanging 
Jump 
Describe:
Time of DSH:
Record weight on A&E card.
Is the patient currently under
the influence of drugs or alcohol? Y N
No. of tablets taken & total dose:
Name of Drug(s):
Quick Look Test:
Does the patient look:
Well (comfortable)?
Unwell (distressed/uncomfortable)?
Critical?
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If the method of harm requires immediate intervention do not use this form.
Please tick appropriate response
Does the person have any immediate plans to harm self or others or damage property?
Is the patient obviously disturbed, threatening, agitated or unpredictable in their behaviour?
Is there any suggestion that the person may abscond?
Does the person have history of violence?
Does the person have a history of mental health problems or self-harm?
Has the person been detained under a mental health section before?
Yes
No
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Issues to be explored through questioning
Background, observations and behaviours
Author/s: Zahidur Rahman
Approved by: Helen May
Date approved: 30.09.15
Review date: 30.09.18
Available via Trust Docs
Trust Docs ID: 3368
Page 1 of 5
History of psychiatric illness or Events leading up to DSH episode:
Questions to ask: To understand how you are feeling, would you like to run through what happened when the crisis started?
Has there been a build up to this?
For DSH: Did you expect to die? Saving tablets? Final acts (Wills, etc.)?
Premeditated (> 3hrs planning)? Measures to prevent discovery? Delay in seeking help? Definite sustained wish to die?
Does the person have any close family/friends/social support?
Physical description – include height, build, distinguishing features, clothing, skin colour, hair colour and
style
Are there any child protection issues?
Is this person in any way vulnerable
□ Yes
□ Yes
□ No
□ No
Consider phoning Social Service
Consider Safe Guarding of Vulnerable Adults
Nurse triage
What level of risk do you think this patient has?
Observation level required
□ High
□ Yes
□ Red
Print name:
Signature:
Designation:
Date:
Time:
Contact/Bleep number:
Has the patient been searched for weapons?
□ Medium
□ No
□ Amber
□ Low
□ Green
The suicide risk screen is for use by doctors or nurses and may be an aid to risk assessment
Suicide risk screen
The greater number of positive responses the higher the risk
Previous self-harm
Previous use of violent method
Current suicide plan
Current suicidal thoughts
Hopelessness/helplessness ***
Low in mood/loss of interest or energy
Displaying bizarre or unpredictable behaviour
Alcohol/drug misuse
Chronic pain or illness
Sense of Guilt/worthlessness?
Yes
No
Maybe
Yes
No
Maybe
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Yes
No
Maybe
Family history of suicide
Unemployed/retired
Male
Separated/widowed/divorced/domestic/violence
Lack of social support
Family concern about risk
Disengaged from services
Poor adherence to psychiatric treatment
Access to lethal means of harm
Loss of self-esteem
*** This is a very sensitive pointer to serious depression
Additional screen for adolescents
The greater number of positive responses the higher the risk
Yes
No
Maybe
Author/s: Zahidur Rahman
Approved by: Helen May
Date approved: 30.09.15
Review date: 30.09.18
Available via Trust Docs
Trust Docs ID: 3368
Page 2 of 5
Do they come from a broken home?
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Is there imminent disciplinary action (not just
the courts)?
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Are there family members with
psychopathology/suicidal (DSH) behaviour
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Do they feel socially alienated?
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Are they at the end of their tether caring
for others (alcoholic parents etc)?
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Are there any school stressors e.g. exams,
bullying, refusal?
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Have they (now or before) run away from
home?
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Are there frequent arguments with someone?
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Are social services involved with care of
the patient or other family members
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Are there relationship problems – include
family, friends and boy/girl friends?
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Any evidence of recent antisocial
behaviour/truancy in self or peers
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Do they use drugs/alcohol?
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Have they had any warnings about their
behaviour?
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Evidence of recent drug use e.g. used like OD
of drugs (not enjoyment to excess)?
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Have they felt humiliated by anyone?
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Evidence of alcohol abuse e.g. used like OD of
drugs (not enjoyment to excess)?
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Doctor’s assessment
After full assessment, what level of risk do you think this patient has?
□ High
□ Medium
□ Low
What level observations should continue?
□ Red
□ Amber
□ None
Print name:
Date:
Signature:
Time:
Designation
Contact/Bleep number:
Outcome:
Admitted to:
AMU:
Hellesdon
Other:
Referred to Bethel clinic 0-17yr old only
see separate Bethel guidance sheet
/
/
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Referred CPN/Access
Discharged – no follow-up
Discharge to GP
Self-discharged
Advice sheet given? Please specify:-
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Summary of levels of risk and suggested actions
Low
No special observations required
Mediu
m
Consider 15 minute amber special observations
High
Start red continuous special observations, inform 3312 of patient’s presence in ED
If the patient absconds, inform 3312, 6537, the doctor in charge, security 5656 and the police
If the patient absconds, inform 3312, 6537, the doctor in charge, security 5656 and the police. Consult the Missing
Patient Procedure if the patient absconds.
Actions to be taken according to level of risk identified
Risk level
Low
Risk factors
Actions
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There may be minor mental health
Treatment and follow up to be arranged by ED team.
Author/s: Zahidur Rahman
Approved by: Helen May
Date approved: 30.09.15
Review date: 30.09.18
Available via Trust Docs
Trust Docs ID: 3368
Page 3 of 5
issues but no plans to harm self or
others.
Medium
High
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Consider referral to primary care services e.g. GP.
May benefit from mental health advice and offer individual relevant advice
booklets.
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No evidence of immediate
vulnerability.
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Person has ideas regarding risky
behaviours towards self or others.
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Implement immediate Amber Special and complete relevant specialling
documentation.
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Mental state likely to deteriorate
without treatment.
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Inform 3312 of the patient’s presence in the Department and ask for assistance
with staffing where necessary.
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Patient is potentially vulnerable.
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Urgent referral to liaison psychiatry team or on call psychiatrist (out of hours).
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If the patient absconds, inform 3312, 6537, the doctor in charge, security 5656
and the police.
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Implement immediate Red Special and complete relevant specialling
documentation.
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Nurse allocated specialling duties to wear alarm to summon immediate help if
patient tries to abscond or attack them.
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Inform 3312 of the patient’s presence in the Deparment and ask for assistance
with staffing where necessary.
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All attempts should be made to stop the patient leaving the department.
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Consult immediately the Missing Patients Procedure if the patient absconds.
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Serious mental health problems
present, including possible
psychosis.
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Patient has strong/immediate plans
to harm self or others.

May have already attempted to
harm self or others.
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Mental Health very likely to
deteriorate if left untreated.

Patient is highly vulnerable.
All attempts should be made to stop the patient leaving the department before
seeing a mental health professional.
If the patient absconds, inform 3312, 6537, the doctor in charge, security 5656
and the police.
Psychiatric management
General comments:
Ambivalence - Beware of sending home the person who is ambivalent or worse about repeating an act of selfharm.
Hopelessness - Someone with a sense of hopelessness (no view of the future) should be taken very seriously.
Disguised intentions - Remember some patients are good at disguising that they are really determined to kill
themselves. Listen to the concerns of relatives.
Factors associated with a high risk of suicide – If your instincts tell you someone is at risk based on a single idea
then act appropriately. A patient could be depressed if no reason or an insignificant reason is given for DSH.
Alcohol and relationship problems - If mainly an alcohol problem they are best dealt with by the alcohol team. If
the main problem is a relationship especially with a marriage partner then the patient should be advised to
contact RELATE.
Adolescents:
Alcohol - Do not need to refer pure alcohol excess due to partying activities provided they are not taking illicit
drugs.
Safety - Will they feel safe going home?
Abuse - Deliberate self-harm may be the route by which child abuse or severe failures of childcare may come to
light.
Remember some young people act as carers for other people e.g. physically or mentally ill relatives, alcoholic
parents etc.
If letting them go:
 Assess suicidal intention and the continuing risk of the young person acting on suicidal or self-damaging
impulses (what did you intend – what do you still intend doing – do they exhibit dangerous impulsive
behaviour)
 Make a preliminary assessment of the young person’s overall mental health and development, their
psycho-social situation and the ability of those adults responsible for them to ensure their safety.
Reasons for admission or immediate referral to child psychiatrist:
1. Suspected child abuse or severe failure of care
Author/s: Zahidur Rahman
Approved by: Helen May
Date approved: 30.09.15
Review date: 30.09.18
Available via Trust Docs
Trust Docs ID: 3368
Page 4 of 5
2. Depression or other serious psychiatric diagnosis
3. No reason or insignificant reason given for DSH – could be depressed
4. Ambivalent or worse feelings about DSH
Author/s: Zahidur Rahman
Approved by: Helen May
Date approved: 30.09.15
Review date: 30.09.18
Available via Trust Docs
Trust Docs ID: 3368
Page 5 of 5