Risk Assessment and Safety Planning Note

Risk Assessment and Safety Planning Note Presenting Concerns and Risk Indicators: Patient reported experiencing increased feelings of hopelessness and anhedonia over the past two weeks, following a recent job loss. Expressed passive suicidal ideation, stating, "Sometimes I just wish I wouldn't wake up." Denied active plans or intent, but acknowledged feeling overwhelmed and isolated. Also noted an increase in alcohol consumption from occasional social drinking to daily use (2-3 glasses of wine per evening). History of Risk Behaviours: Patient disclosed a history of depression with a previous episode five years ago that resulted in a brief hospitalisation due to severe anhedonia. No prior suicide attempts or self-harm behaviours reported. No history of aggression or domestic violence. No known substance-related high-risk incidents beyond current increased alcohol use. Protective Factors and Strengths: Patient has strong family support, particularly from their sister who lives nearby and checks in regularly. Expressed a desire to "feel better for my kids" and acknowledged the importance of maintaining their role as a parent. Possesses good insight into their emotional state and willingness to engage in therapy. Actively involved in a local community gardening group. Current Risk Assessment: Moderate risk. While denying active suicidal intent or specific plans, the presence of passive suicidal ideation, recent job loss, increased alcohol use, and a history of depressive episodes elevate the risk level. There is no immediate imminent danger, but close monitoring and active safety planning are crucial. Safety Plan Components: - Agreed to remove all alcohol from the home immediately and limit access. - Identified sister, Sally, and best friend, Melinda, as primary emergency contacts. Patient has their numbers readily available. - Committed to not being alone for extended periods, especially in the evenings, and will stay with their sister for the next few days. - Will attend a virtual support group for job loss and depression starting 1 November 2024, as discussed. - Identified deep breathing exercises and calling their sister as grounding techniques to use when feeling overwhelmed. Referral or Escalation of Care: No immediate emergency services contact was required. Discussed the possibility of connecting with a psychiatrist for medication management if symptoms do not improve with therapy. Patient agreed to consider this option if recommended at the next session. Follow-up Plan: Next therapy session scheduled for 1 November 2024, at 10:00 AM. Agreed to a telephonic check-in from the counselor on 30 October 2024 to monitor mood and adherence to safety plan. Patient will keep a mood journal and track alcohol intake until the next appointment. Clinician Specialty: Counselors