ASQ Screening Tool

Ask the patient:

Next steps:

• If patient answers “No” to all questions 1 through 4, screening is complete (not necessary to ask question #5). No intervention is necessary (*Note: Clinical judgment can always override a negative screen).
• If patient answers “Yes” to any of questions 1 through 4, or refuses to answer, they are considered a positive screen. Ask question #5 to assess acuity:
  • “Yes” to question #5 = acute positive screen (imminent risk identified)
    • Patient requires a STAT safety/full mental health evaluation. Patient cannot leave until evaluated for safety.
    • Keep patient in sight. Remove all dangerous objects from room. Alert physician or clinician responsible for patient’s care.
  • “No” to question #5 = non-acute positive screen (potential risk identified)
    • Patient requires a brief suicide safety assessment to determine if a full mental health evaluation is needed. If a patient (or parent/guardian) refuses the brief assessment, this should be treated as an “against medical advice” (AMA) discharge.
    • Alert physician or clinician responsible for patient’s care.

Provide resources to all patients

• 24/7 National Suicide Prevention Lifeline, 988
• 24/7 Crisis Text Line: Text “HOME” to 741-741