SBQ-R

First Name *

Last Name *

Date of Birth *

Instructions: Please select the statement or phrase that best applies to you.

Have you ever thought about or attempted to kill yourself?

NeverIt was just a brief passing thought I have had a plan at least once to kill myself but did not try to do itI have had a plan at least once to kill myself and really wanted to die I have attempted to kill myself, but did not want to die I have attempted to kill myself, and really hoped to die

How often have you thought about killing yourself in the past year?

Have you ever told someone that you were going to commit suicide, or that you might do it?

No Yes, at one time, but did not really want to die Yes, at one time, and really wanted to do it Yes, more than once, but did not want to do it Yes, more than once, and really wanted to do it

Total