Circle your responses below 

1.    On a scale of one to ten, how intense is your present mood?

 Least Intense    1   2   3   4   5   6   7   8   9   10    Most Intense

2.    Rank on a scale of one to ten your present ability to control your urges and moods.

      In Control    1   2   3   4   5   6   7   8   9   10    Out of Control

3.     How intense are your suicidal tendencies?

Non-existent    1   2   3   4   5   6   7   8   9   10    Real Threat/Acting On Them

4.    How intense is your desire to harm yourself in ways like slashing your body, burning yourself with things like cigarettes, walking in front of cars, etc.?

Least Intense    1   2   3   4   5   6   7   8   9   10    Most Intense

5.    Do you have a plan in mind of how you will commit suicide?

No    1   2   3   4   5   6   7   8   9   10    Yes

 Sort Of 

6.    Have you made any attempts to carry out your plans to kill yourself? Have you written a note, attempted but changed your mind, or attempted but were discovered?

   No    1   2   3   4   5   6   7   8   9   10    Yes

Sort Of

Low Risk

This category describes those people who are experiencing emotional upset but are still able to function in their surroundings with a degree of satisfactory coping mechanisms.  They can seek out emotional support from sources in their community.