Risk Assessment – Comprehensive
Session Note Template:
This comprehensive risk assessment and management plan template in NovoNote can be used by a wide variety of clinicians to document a comprehensive risk assessment and management plan based on information from a session with a client or patient. It covers suicidal and homicidal ideation, non-suicidal self-injury, past risk history, psychosocial risk factors, protective factors, structured risk instruments, and risk mitigation actions.
For a concise risk assessment, clinicians may wish to use the related template, Risk Assessment – Brief.
Please note: While this template is intended to be broadly applicable, it is important that clinicians review outputs to confirm accuracy and ensure compliance with their specific state, organisational, governmental, legal, and ethical regulations, and assume responsibility for executing and documenting all clinically indicated follow-up actions.
Template Structure
Example Output
Template Structure
Mental Status Examination:
- Behaviour: Describe client’s activity level and notable behaviours.
- Speech: Comment if speech was unusually fast or slow.
- Mood: Record client’s reported emotional state.
- Affect: Describe client’s emotional expression and range.
- Thoughts: Note thought processes and content, including any abnormalities.
- Perceptions: Record any hallucinations or sensory issues.
- Cognition: Describe memory, orientation, concentration, comprehension.
- Insight: Comment on client’s understanding of their condition.
- Judgment: Describe client’s decision-making ability.
Current Risk Concerns:
- List only categories identified this session: suicidal ideation, homicidal ideation, violence/aggression, auditory hallucinations, visual hallucinations, non-suicidal self-injurious behaviour, intimate partner violence, other
- Print “None identified” if no concerns are present
Details for Present Risk:
- Suicidal ideation — passive vs active, frequency/duration, method, intent, plan, timeline, preparatory behaviour, access to lethal means; each element stated as present with detail, denied, or not documented
- Homicidal ideation — passive vs active, target, method, intent, plan, preparatory behaviour, access to lethal means; each element stated as present with detail, denied, or not documented
- Violence/aggression — nature, severity, triggers, frequency, target (specific vs general); distinguished from homicidal ideation
- Non-suicidal self-injury — nature, method, frequency, most recent occurrence; distinguished from suicidal behaviour
- Hallucinations — type, content, frequency, impact; command hallucination content and compliance/resistance if present
- Intimate partner violence — explicitly stated or observed safety concerns within the relationship
- Other — additional concerns not captured above, including mandatory reporting concerns (child, elder, or dependent adult abuse/neglect) and the relevant category
- Direct client/clinician quotes included only where documented, attributed as “client reported” or “clinician observed”
- Psychosocial risk factors — social isolation, bullying, financial difficulty, legal issues, bereavement, indicators of grave disability, other stressors
- Print “No risk concerns identified” if the Current Risk Concerns list was empty
History of Risk Behaviour:
- Previous suicide attempts — number, method, date of most recent, medical lethality where documented
- Previous non-suicidal self-injury
- Previous psychiatric hospitalisations related to risk
- History of violence or aggression toward others
- Each item stated as present with detail, denied, or not documented; print “History of risk behaviour: Not documented” if none of the above are documented
Psychometric Assessment Results
(Include only if administered and documented)
- Instrument name, date administered, result/score as documented, clinical interpretation as documented
- May include C-SSRS, ASQ, or other documented instruments
Interventions and Protective Factors:
- Interventions — safety planning, means restriction counselling, crisis resources, action on any third-party threat, level of care recommendation/referral, follow-up plan
- Protective factors — social support, reasons for living, future orientation, religious/cultural beliefs, treatment engagement, medication adherence, restricted access to lethal means
- Print “No interventions or protective factors documented” if nothing to report
Example Output
Mental Status Examination:
- Behaviour: Mary was cooperative and maintained appropriate engagement throughout the session. No psychomotor agitation or retardation observed.
- Mood: “Pretty flat, I guess — tired of feeling like this.”
- Affect: Constricted range, congruent with stated mood.
- Thoughts: Logical and linear. Suicidal ideation present — see below.
- Cognition: Alert and oriented to time, place, and person. No documented concerns with attention or memory.
- Insight: Recognised current difficulties as related to ongoing stress and low mood; engaged readily in discussion of support options.
- Judgment: Intact; able to identify appropriate steps to manage safety.
Current Risk Concerns:
- Suicidal ideation
Details for Present Risk
Suicidal Ideation
- Passive ideation reported, occurring several times over the past two weeks, lasting minutes at a time
- Active ideation: Denied
- Method: Denied
- Intent: Denied
- Plan: Denied
- Timeline: Not applicable — no plan reported
- Preparatory behaviour: Denied
- Access to lethal means: Not documented
- Client reported: “I’ve had thoughts that I wouldn’t mind not waking up, but I’d never do anything about it.”
- Clinician observed: Mary maintained eye contact and engaged openly when discussing these thoughts, without distress escalation.
Psychosocial Risk Factors
- Reports reduced social contact over the past month following a reduction in work hours
- No other psychosocial stressors documented
History of Risk Behaviour:
- Previous suicide attempts: Denied
- Previous non-suicidal self-injury: Present — one episode of superficial cutting to forearm at age 16; no episodes since
- Previous psychiatric hospitalisations related to risk: Denied
- History of violence or aggression toward others: Not documented
Interventions and Protective Factors:
- Safety plan developed collaboratively, including early warning signs (increased withdrawal from friends, disrupted sleep), coping strategies (calling her sister, going for a walk, using a grounding app on her phone), and identified support contacts
- Crisis line information (988 Suicide & Crisis Lifeline) provided
- Follow-up session scheduled in one week to review mood and safety plan
- Protective factors: strong relationship with sister, described as “someone I can always call”; future orientation expressed regarding an upcoming work project; no current alcohol or substance use reported as a compounding factor
- Template Type
- Session Note
- Assessment Session
Author:
Dr Carla Smyth
Research Fellow & Clinical Psychologist
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