Risk Assessment in Mental Health: A Complete Guide for Professionals

Mental health risk assessment is the systematic evaluation of whether someone might harm themselves or others, and yet it’s the most critical skill you’ll never feel fully prepared for. Despite being fundamental to treatment planning and legal documentation, most clinicians still get a pit-in-the-stomach feeling when a session takes a turn toward safety concerns.

It’s late Friday, and your final session is just beginning. You’re running low on energy, already thinking about dinner plans you’ve had on your mind all week. You’re tired, already half-thinking about that new restaurant you’ve been meaning to try. Then they drop it: “I’ve been thinking… maybe I shouldn’t be here anymore.” Your heart rate? Through the roof. Weekend plans? Gone. Been there? Of course, you have. It doesn’t matter if you graduated last month or have been doing this since the Clinton administration. One minute, you’re talking about work stress; the next, you’re frantically trying to remember what safety screening tools you have on hand. That moment of panic?

This guide is here for it, your practical walkthrough for handling clinical safety conversations with confidence.

What is a Mental Health Risk Assessment? (And Why it’s Not Just About Suicide)

A mental health safety evaluation is your structured way of wrestling with two huge questions:

How likely is this person to harm themselves or someone else?
What kind of support is needed right now?

You’re also asking yourself:

Could they hurt someone else? That might mean lashing out at a family member or someone in their orbit.
Are they eating? Taking meds? Is where they’re living actually safe?
Are they taking more chances than usual, substance use, driving too fast?
Do they seem isolated or confused?

Pro Tip: Conversations about safety are never one-and-done. What someone says this week might shift by next. Keep checking in.

How to Use Key Tools Effectively

Many of us first learned about safety screening tools in training that felt abstract. But in real practice, they need to feel natural. Here are a few that can help you get your footing.

The Columbia Suicide Severity Rating Scale (C-SSRS)

If the C-SSRS isn’t in your rotation yet, it’s time to change that

Here’s the thing about using it well:

Don’t run down the list like a script. Rather than reading straight from a form, follow the conversation. If a client says they’ve been feeling stuck, that’s a moment to lean in a little. You might say, “Sounds like things have been heavy. Have you ever had thoughts about not wanting to be around anymore?”
Pay attention to where they land on the spectrum. The C-SSRS lays out how thoughts can move from vague unease to concrete planning. That helps you determine whether this is something to track, or act on now.
Use behavioral markers. Don’t just focus on words. Have they made a plan? Given away belongings? Researched methods? These actions tell you just as much as the conversation.

The CASE Approach: For When You Need More Depth

The CASE Method (Chronological Assessment of Suicide Events) helps explore someone’s suicidal thinking across time. What’s changed? What patterns are emerging? Where’s the progress? The CASE approach is particularly helpful when you’re working with clients who’ve been struggling for a long time with suicidal thoughts and need a space to unpack, not just report.

Key Reminders

Intent doesn’t always match lethality. Someone might be determined, but choose a method that’s unlikely to be fatal. Others might act impulsively with dangerous means. Ask about both.

The “I Won’t Do Anything” Promise: Getting clients to promise they won’t hurt themselves isn’t protective or productive. What is protective? Collaborative safety planning. This planning gives them specific alternatives for when they’re in crisis.

Common Mistakes (That We’ve All Made)

The “They Seem Better” Trap: Risk can increase when depression starts lifting because the person has more energy to act on suicidal thoughts. Don’t decrease monitoring just because a client’s mood improves.

The Hospitalization Reflex: When a client shares thoughts of distress or hopelessness, inpatient care may not always be the most appropriate or helpful response. You may also risk damaging therapeutic relationships and creating unnecessary trauma.

The Documentation Disaster: Writing “low risk” without explaining why. Your future self (and possibly lawyers) need to understand your reasoning.

The Resource Assumption: Assuming clients have social support, transportation, or financial resources they don’t have. Always assess for practical barriers to safety.

Tools That Actually Work

These are the tools clinicians often reach for in everyday practice:

Quick Screening Tools (Typically finished in 2-3 minutes)

SAD PERSONS Scale

The Basics: 10-item checklist, quick scoring system
Best Settings: Emergency screening, triage situations
Strengths: Fast, easy to remember, good for newer clinicians
Limitations: Oversimplifies complex risk, limited predictive value for individuals, works primarily for initial screenings

What it stands for:

Each letter in SAD PERSONS stands for:

S – Sex
A – Age (under 19 or over 45)
D – Depression or feelings of hopelessness
P – Previous suicide attempt
E – Excessive alcohol or substance use
R – Loss of rational thinking (e.g., due to psychosis or illness)
S – Lacks social support
O – Organized or serious suicide plan
N – No partner (single, divorced, or widowed)
S – Sickness (chronic or terminal illness)

Brøset Violence Checklist (BVC)

The Basics: 6 behavioral observations, simple yes/no format
Best Settings: Inpatient units, emergency departments
Strengths: Quick, observation-based, reasonable short-term prediction
Limitations: Only predicts next 24-48 hours, requires direct observation

Comprehensive Assessment Tools (Can range from 10-90 minutes)

Columbia Suicide Severity Rating Scale (C-SSRS)

Best Settings: Most clinical settings when you need standardized assessment
When to Use: Initial screenings, tracking changes over time

CASE Method

Best Settings: Outpatient therapy sessions
When to Use: When you need a deeper understanding

HCR-20 (Historical Clinical Risk Management-20)

The Basics: 20 items across three domains, structured professional judgment
Best Settings: Forensic units, specialized violence assessment programs
Strengths: Comprehensive, well-validated, includes risk management factors
Limitations: Training-intensive, time-consuming, requires significant clinical experience

Specialized/Multi-Risk Tools (Generally around 30-45 minutes)

START (Short-Term Assessment of Risk and Treatability) Manual

The Basics: 20 dynamic factors, covers multiple risk domains
Best Settings: Community mental health, case management programs
Strengths: Addresses multiple risks simultaneously, including protective factors
Limitations: Complex scoring, requires training, still developing research base

Top Tip: Start with one tool you can use confidently. Build from there.

Making Documentation Easier

Wish you had a form that wasn’t overwhelming? Use this template to document clearly:

CLIENT INFORMATION

Name: DOB:
Date of Assessment: Time:
Evaluated by: Setting:
Reason for Assessment:

CURRENT PRESENTATION

Current mental state:
Presenting concerns:
Recent stressors/triggers:
Substance use (current):

RISK ASSESSMENT

Suicide Risk:

Current suicidal ideation: □ None □ Passive □ Active
Details of plan and means access: □ Yes □ No Details:
Previous attempts: □ Yes □ No When/How:
Protective factors:

Violence Risk:

Thoughts of harming others: □ Yes □ No
Specific targets:
History of violence: □ Yes □ No Details:
Current triggers:

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Self-Care/Neglect Risk:

Medication compliance: □ Good □ Poor □ N/A
Basic self-care: □ Adequate □ Concerning
Living situation safety: □ Safe □ Unsafe
Details:

PROTECTIVE FACTORS

Social support:
Coping strategies:
Reasons for living:
Treatment engagement:

CLINICAL TOOLS USED

C-SSRS Score:
SAD PERSONS Score:
Other:

RISK LEVEL DETERMINATION

Low Risk, Moderate Risk, High Risk
Rationale:

IMMEDIATE INTERVENTIONS

Safety planning, Increased monitoring, Hospitalization
Crisis team contact, Family notification
Specific actions:

FOLLOW-UP PLAN

Next contact:
Frequency:
Specific monitoring:

ADDITIONAL NOTES

CLINICIAN SIGNATURE & DATE

Documentation Example – Key Fields:

Mental state: Depressed, tearful, low energy, hopelessness present

Current ideation: Passive “Sometimes think everyone would be better off without me.”

Risk determination: Moderate Risk

Rationale: Passive suicidal ideation with multiple stressors but strong protective factors. No intent or plan. Increased alcohol use concerning.

Actions taken: Safety plan completed, excess medications removed, sister to check daily, crisis line number provided

Clinical Documentation from the Frontlines: The Nursing Perspective

Nurses often catch the first signs that something’s off, changes others might miss in passing. You’re watching for subtle shifts in how someone moves through their day, what’s said (and unsaid), and how their body responds to stress.

Here are just a few things nurses tend to notice early:

A client who stops eating regularly or isn’t sleeping well
Missed medication doses, side effects, or new reactions
Agitation that builds slowly between formal evaluations
Family visits that seem to spark distress or withdrawal

When you’re documenting, go beyond vague phrases like: “appeared anxious.” Instead, try something like, “Client avoided eye contact, sat with arms crossed, voice shook while discussing discharge plans.”

NICE Guidelines (UK): What You Need to Know

The UK’s NICE guidelines for risk assessment emphasize several key points that apply universally:

Structured clinical judgment over actuarial tools – Use tools to inform, not replace, clinical thinking
Routine inquiry about suicidal thoughts – Ask everyone, not just high-risk clients
Consider protective factors alongside risk factors – What’s keeping this person safe? What are their triggers?
Document rationale for decisions – Explain your clinical reasoning
Regular review and reassessment – Risk changes over time

Building Your Process

1. Preparation

Know your local crisis numbers ahead of time, and clarify what your clinic or team expects if things become urgent. When something escalates, that’s not the moment to go hunting through a binder.

2. Systematic Inquiry

Begin broadly, then focus specifically
Integrate structured tools naturally into the conversation
Explore risk factors alongside protective factors

3. Clear Decision Making

Low risk: Basic safety planning
Moderate risk: Increased contact frequency, specific interventions, family involvement
High risk: Immediate safety measures, possible hospitalization consideration

When Things Go Wrong: The Hard Conversations

Sometimes, things go sideways. You might’ve felt confident about where someone was at; maybe they seemed grounded, even optimistic, and then something shifts. People are complicated, and outcomes don’t always follow logic or effort.

Remember this:

You’re not being asked to predict what happens next, just to respond with care, clinical reasoning, and clarity.
Reach out for help. Supervision isn’t a luxury; it’s protection.
Take care of yourself. Clinical work around safety is heavy. Don’t carry it solo.

Implementation Checklist You Can Use

Before Assessment

Review available background information

Prepare assessment tools and ensure privacy

Consider environmental factors

During Assessment

Build rapport and begin with open-ended questions

Assess multiple risk areas and protective factors

Include client in risk level determination

After Assessment

Document observations and clinical reasoning

Complete safety planning if needed

Schedule appropriate follow-up

The Bottom Line

No checklist makes this work easy. Risk assessment is about showing up fully, asking hard questions, and making your best call, sometimes with your gut in knots. You won’t always have a clear answer. There won’t always be a clear answer. You may leave some sessions wondering whether you did enough and that uncertainty is part of the work. What matters most is staying present, asking thoughtful questions, and offering steady care in moments that are rarely simple.

Here’s one less thing to carry around in your head: if you’re using Mentalyc’s recording feature, the full conversation is saved, word for word. So when your notes feel thin or your memory’s foggy from a long day, you have something solid to return to. No guesswork. And when the stakes are high, having that backup can take a real weight off your shoulders.

FAQs About Navigating Safety in Mental Health

What are we really doing when we assess risk?

You’re not just completing a form. You’re trying to understand where someone’s at, what’s rising beneath the surface, and what kind of care fits best right now.

Why are mental health risk assessments so important?

In a crisis, guessing your way through isn’t enough. A solid risk assessment helps you catch changes early, identify what’s being built, discern what’s being said between the lines and determine how to respond before it escalates. It’s how we show up fully for our clients and protect their safety.

What kinds of risks should I assess?

You’re looking at more than just suicide risk, though that’s huge. You’re also watching for:

Whether they might hurt themselves
Signs they could harm someone else
Keep an eye on the basics: Are they getting enough to eat? Sleeping? Taking their medications as prescribed?
Watch for impulsive decisions, as these can put them in danger quickly.
Check for vulnerability: are they in environments or relationships where someone might take advantage of them?

What tools should I use for risk assessment?

Go with what works in your setting and feels natural to use:

C-SSRS: Reliable for suicide risk, especially when it’s part of a real conversation.
SAD PERSONS: Super quick in a pinch; just don’t let it be the only thing you rely on.
CASE: Really useful when someone’s been dealing with suicidal thoughts for a long time.
HCR-20, START, and Brøset: You’ll see these more in hospitals or forensic units. You’ll need some training, but they’re strong frameworks when used right.

None of them replace your judgment. They just help organize it.

How do assessments guide care?

They won’t always give you a clear yes or no, but that’s not the point. What they do offer is direction. Maybe it’s a sign to check in more often, bring in a family member, work on a safety plan, or call in extra support. Whatever the next step is, you’ll have something solid to base it on.

What if I’m not sure what to do?

Checking in with a supervisor or peer can offer the clarity you need to move forward with confidence.

References

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Assessment and management of patients at risk for suicide. (2019). VA/DoD Clinical Practice Guidelines.

Chaplin, S. (2023). NICE on the assessment and management of self-harm. Prescriber, 34(1), 21–22.

Clinical guidelines on risk assessment. (2025). National Confidential Inquiry into Suicide and Safety in Mental Health.

Conlon, D., Raeburn, T., & Wand, T. (2024). Mental health risk assessments of patients, by nurses working in mental health settings: a qualitative study using cognitive continuum theory. Issues in Mental Health Nursing, 45(5), 488–497.

Fedorowicz, S. E., Dempsey, R. C., Ellis, N., Phillips, E., & Gidlow, C. (2023). How is suicide risk assessed in healthcare settings in the UK? A systematic scoping review. PLOS ONE, 18(2), e0280789.

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National Institute for Health and Care Excellence. (2022a). Self-harm: Assessment, management and preventing recurrence. National Institute for Health and Care Excellence.

National Institute for Health and Care Excellence. (2022b). Self-harm: assessment, management and preventing recurrence NICE guideline.

NICE guidelines developed by NCCMH. (2025). Royal College of Psychiatrists.

NICE social care mental health guidance. (2025).

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Royal College of Psychiatrists. (2016). Assessing and managing risk of patients causing harm.

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Suicidal Ideation and Behavior – C-SSRS Screening Questions. (n.d.). In Prevent Suicide NY.

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The strengths and limitations of risk assessment. (2015). Center for Justice Innovation.

White paper: On the principles of mental health risk assessment. (2024). In Victoria State Government Department of Health.