SAFE-T Assessment PDF: 5 Steps, Template and 2 Examples

If you're looking for the SAFE-T assessment PDF, the official copy is SAMHSA's two-page card, updated in December 2024, and the link is below. Many copies that come up for this search are older: the 2009 pocket card is still posted widely, with the Lifeline's old 10-digit number on it. This page is everything around the card for a therapist in private practice: the five steps in plain words, what each risk level means for what you do before the client leaves, how to run the assessment by video, a suicide risk assessment documentation template you can copy, two example notes, follow-up, and what research says risk assessment can't do.

If you are thinking about suicide, or worried about someone, right now: in the US, call or text 988 or chat at 988lifeline.org. If someone is in immediate danger, call 911 or go to the nearest emergency room. Outside the US, call your local emergency number or crisis line.

SAFE-T is a way to organize a clinical assessment. It doesn't replace your training, consultation, your setting's risk policy or your state's rules, and neither does this page. The wording here is ours, adapted from SAMHSA's card, and the actions for each risk level are a starting point to adapt with a supervisor or consultant.

Every client in this article is invented. Any resemblance to a real person is a coincidence.

Where to get the official SAFE-T assessment PDF

SAMHSA lists the card in its library as SAFE-T Suicide Assessment Five Step Evaluation and Triage, publication ID PEP24-01-036, dated December 2024. The PDF itself is two letter-size pages: the five steps, lists of risk and protective factors, the questions for the suicide inquiry, a chart of risk levels with possible interventions, what to document, and a list of resources.

The footer reads "HHS Publication No. (SMA) 09-4432 ... Updated 2024." That's the same number the 2009 card carried, so look for "Updated 2024" and for 988 on any copy someone hands you. Other versions you'll find:

Is the SAFE-T card in the public domain?

As a SAMHSA publication, yes. The SAMHSA Library's "Public Domain and Copyright" section says: "SAMHSA publications are in the public domain. You may download, reproduce, or copy them without permission as long as you do not sell them for a fee" (SAMHSA Library, Help). The same section adds conditions:

The card itself carries no copyright or public domain notice. Its acknowledgments credit the idea to Douglas Jacobs, MD, say it was developed by Screening for Mental Health, Inc. and the Suicide Prevention Resource Center, and say the material is based on work supported by a SAMHSA grant.

For a private practice, that means you can print the official PDF, keep it at your desk, and build its steps into your own intake or note template with SAMHSA and PEP24-01-036 cited. Leave the logos off anything you adapt, and don't charge for it. This page describes the steps in our own words and links to SAMHSA's PDF rather than reproducing it. As SAMHSA suggests, here is its disclaimer: "Inclusion of SAMHSA content does not constitute or imply endorsement or recommendation by the Substance Abuse and Mental Health Services Administration, the U.S. Department of Health and Human Services, or the U.S. Government."

What SAFE-T stands for, and the five steps

SAFE-T stands for Suicide Assessment Five-Step Evaluation and Triage. The five steps, in our words:

There's no score. SAMHSA says the risk level rests on clinical judgment after the first three steps. The card is a checklist for a conversation you're already trained to have, so that nothing important gets skipped when a session turns serious.

What changed in the 2024 SAFE-T

Reading the 2009 card and the 2024 update side by side, the main changes are:

Otherwise, the step 3 questions are nearly the same in both versions.

When to do a SAFE-T assessment

SAMHSA lists four times: at first contact; after any new suicidal behavior, increased ideation or relevant clinical change; before changes in behavioral health treatment; and at discharge from inpatient care. In a private practice, that usually means:

SAMHSA also says to reassess whenever the client's circumstances or surroundings change. A level describes today, not next month.

Step 1: Identify risk factors

The 2024 card lists nine risk factors. Here they are in our words, with a note on whether each can be changed, which is what SAMHSA asks you to mark:

The card also lists populations at increased risk for suicide: American Indian, Alaska Native and Tribal communities; Black youth; rural communities; LGBTQI+ youth and young adults; middle-aged men; and older adults. Read these as context. They describe higher rates across groups, not the risk of the person in front of you, so ask about the experiences that can sit behind the numbers, such as rejection, discrimination or distance from care.

Most of step 1 comes from your intake: history, substance use, medical conditions, family history. What the intake can't tell you is what's recent, so ask what has changed in the past weeks. The 2009 card asked about triggering events that bring humiliation, shame or despair, such as the loss of a relationship, money or health, real or expected. Those are still worth asking about.

Step 2: Identify protective factors

The 2024 card lists six protective factors:

The card adds a warning: protective factors, even when present, may not counteract significant acute risk. A loving family may not offset a plan and intent for tonight.

A few things make this step useful rather than a list of comforts:

Step 3: Conduct the suicide inquiry

The inquiry is the center of the assessment. The card lists what to ask about, which in our words is:

For young people, the card asks you to talk with a parent or guardian about any history of suicidal thoughts, plans or behavior, and changes in mood, behavior or disposition.

How to ask in a session:

Step 4: Determine the risk level and intervention

SAMHSA makes three points about step 4. The risk level is based on clinical judgment after steps 1 to 3. You reassess as the client's circumstances change. And you develop a safety plan at every level.

The card's chart, in our words:

SAMHSA notes that the chart shows examples of a range of risk levels and interventions, "not actual determinations."

Real clients often fit none of the rows. Recent suicidal behavior, for example, rules out the low and moderate rows as written, but the high row is defined by plan, method and intent. A client with no plan but a recent loss, heavy drinking and a gun at home doesn't fit cleanly either. Those are the cases to consult on before the client leaves, and to explain in your note.

Some clinicians add a short risk formulation to the level: why the risk is what it is now, what could raise it, and what is keeping it down. It makes your reasoning clear to the next reader, and it points straight at the plan.

How SAFE-T risk levels map to actions in an outpatient practice

SAMHSA's chart was written with clinics and hospitals in mind, where an "outpatient referral" means sending someone to a therapist. In a private practice you're usually the outpatient care already, so each level is really a question of what you do before the session ends, this week and from now on. Here's one way to lay it out. Adapt it with a consultant, your liability carrier's guidance and your state's rules, and write your version down before you need it.

Low risk

Before the client leaves:

This week and ongoing:

Moderate risk

Before the client leaves:

This week:

Ongoing:

High risk

In this session:

Afterward:

SAMHSA's chart allows that a significant change in the session can reduce the risk. A client who hands the method to a family member who is there, and whose intent has clearly gone, may not need emergency treatment. That's a judgment to make with a consultant, not alone, and the reasons go in the note.

Running a SAFE-T assessment by telehealth

The steps are the same by video. What changes is that the client isn't in your building, and the emergency services near you usually can't reach them. HHS's page on creating an emergency plan for telebehavioral health says to record these before the first video visit:

HHS also suggests encouraging the client to write down national and local crisis lines.

In every session, not just the first:

Licensing matters here too. HHS's page on licensure for behavioral health says professionals must meet the licensure requirements of the state where they are located and be licensed or legally permitted to practice in the state where the patient is located. It adds that an emergency plan is especially essential for out-of-state providers practicing telehealth. Our page on counseling compact states covers the compacts, and our telehealth consent form shows how to get the emergency plan agreed in writing at the start of care.

Lethal means counseling, briefly

The 2024 card puts counseling on access to lethal means in what you document. Harvard's Means Matter project describes it as assessing whether a person at risk has access to a firearm or other lethal means, and working with them and their family and supports to limit that access until they are no longer at elevated risk (Means Matter, Lethal Means Counseling). The essentials:

Our safety plan template covers the conversation in full, including how to raise firearms without judging gun ownership and what to do if off-site storage isn't possible.

Step 5: Document the assessment

SAMHSA's documentation step, in our words, asks you to record:

It adds that clients should receive a copy of their safety plan, and that for young people the treatment plan should include roles for a parent, guardian or other supportive adult.

What makes a risk note useful to the next reader:

A suicide risk assessment documentation template you can copy

This template follows the five steps. Paste it into a blank note or the assessment section of your usual format, fill in what applies, delete what doesn't, and keep the order so your notes compare well over time.

Example 1: a low-risk assessment by video

Invented client: a 41-year-old project manager we'll call Elena, in her seventh session of therapy for depression after a layoff, seen by video. Her PHQ-9, sent before the session, scored 14 (16 at intake), with item 9 answered "not at all." Midway through the session she said that some mornings she wishes she wouldn't wake up.

Step 1, risk factors. Fixed: depression, first episode at 24; an uncle died by suicide when she was 16. Changeable: laid off eight weeks ago; drinking two glasses of wine most evenings, up from weekends only; alone at home most days. Recent change: turned down for a job she wanted last week.

Step 2, protective factors. Present now: close to her husband and 9-year-old son ("I'd never do that to them"); her faith, which she says forbids suicide; attends every session and is doing the activity schedule; no firearms in her home or her parents' home. To strengthen: contact with two former coworkers she has been avoiding; daytime structure.

Step 3, suicide inquiry. Ideation, last 48 hours: none. Past month: a wish not to wake up, two or three mornings a week, lasting a few minutes, "a heavy feeling that passes once I'm up." Denied thoughts of killing herself. Worst ever: similar passive thoughts at 24, without a plan. Plan: none. Means: no firearms; sertraline, 30-day supply; a small supply of over-the-counter pain relief. Preparatory acts: none. Past behavior: no attempts, aborted attempts or rehearsals; no self-injury. Intent: none. "I don't want to die. I want this feeling to stop." Reasons for living: "My son. Seeing him grow up." Reasons for dying: "Not feeling useless." PHQ-9 item 9 was "not at all" this morning; she said she didn't think a wish not to wake up counted. Mental status: casually dressed, good eye contact, affect constricted and brighter when talking about her son, thinking clear and organized, insight and judgment good. No alcohol today.

Step 4, risk level and intervention. Risk level: low. Rationale: passive thoughts of death without a plan, intent, preparation or past behavior; strong protective factors that are present now (family, faith, engagement in therapy); the main risk factors are changeable (unemployment, isolation, more drinking). Risk is higher than at intake, when she denied thoughts of death, and the family history is noted. Level of care: weekly outpatient therapy continues; it fits because there is no plan or intent, she is engaged, she has support at home and no access to firearms. Safety plan: written together today (warning sign: waking at 4 AM and staying in bed; coping: get up, shower, walk the dog; people: husband, sister; professionals: this office during business hours, 988). She wrote it out during the session and kept a photo on her phone. Lethal means: no firearms at either home; agreed to keep only a small supply of over-the-counter medication. Crisis numbers: 988 (call, text or chat), 911. Consultation: not needed today. Contact with others: none; she plans to show her husband the safety plan herself.

Step 5, follow-up. Next contact: 10/27 by video. Reassess at the start of that session, and sooner if the thoughts become thoughts of killing herself, a plan appears, or her drinking rises. Treatment plan updated with a goal to cut evening drinking to weekends, and two contacts with friends this week. If she misses the session: a call the same day, as agreed at intake.

Why this note works:

Example 2: a moderate-risk assessment by video, from a new location

Invented client: a 54-year-old electrician we'll call Ray, three months into therapy for depression after a divorce, with chronic back pain, usually seen by video from his apartment. Today he joined from his brother's guest room in another town in the same state, where he was staying for the weekend. When asked about his week, he said, "I've been thinking about my pills."

Step 1, risk factors. Fixed: recurrent depression. Changeable: drinking four or five beers most nights, up from one or two; access to lethal means (his prescribed pain medication, leftover tablets from an earlier prescription, and a hunting rifle in a locked case in his apartment, with him holding the key); alone most evenings since the divorce; hopeless "for months." Partly changeable: chronic back pain and poor sleep. Recent change: divorce final last month; sees his teenagers every other weekend. Context: middle-aged man, a group SAMHSA lists at increased risk.

Step 2, protective factors. Present now: his two teenagers; his brother, who lives 20 minutes from him and knows about the depression; attends every session. To strengthen: his brother's role; pain care with his doctor; contact with a friend from work.

Step 3, suicide inquiry. Ideation, last 48 hours: yes, last night for about an hour, strength 7 out of 10. Past month: thoughts of killing himself four or five nights a week, mostly when his children are with their mother. Worst ever: now. Plan: take all of his pain medication with alcohol at his apartment on a weekend without his children. Means available: the current bottle of pain medication is with him at his brother's home; the leftover tablets and the rifle are at his apartment. Preparatory acts: denied counting or setting aside pills, looking up doses or writing a note. Past behavior: no attempts, aborted attempts or rehearsals; no self-injury. Intent: "I'm not going to do it. My kids would know what I did. But some nights I don't know." Believes the method would be lethal. Reasons for living: "My kids, and my brother." Reasons for dying: "The pain, and being a burden." PHQ-9 before the session: 19, item 9 "more than half the days." Mental status: unshaven, speech slowed, affect flat, tearful once, thinking logical, no psychotic symptoms, judgment fair. No alcohol today.

Step 4, risk level and intervention. Risk level: moderate. Rationale: active thoughts of suicide with a plan (method, place, timing) and access to the method, without stated intent, preparation or past behavior; several risk factors (rising alcohol use, recent divorce, isolation, months of hopelessness, chronic pain, access to opioids and a firearm); protective factors present but strained. His "some nights I don't know" raised concern and was explored: he said the doubt comes when he has been drinking alone. Level of care: outpatient care with more contact. Why: no intent, preparation or past attempts; he agreed to every means step in the session; his brother is engaged; he is staying with his brother through Sunday; the plan was reviewed with a consultant. Would move to an emergency evaluation if intent emerges, a means step isn't completed, or he drinks alone with access to the method. Safety plan: written together (warning signs: Friday nights without his children, drinking alone; coping: call his brother, go to the gym, watch a game at a friend's; people: brother, a friend from work; professionals: this office, 988, the county crisis line). He wrote it down during the session and sent a photo to his brother. Lethal means: with his verbal consent, his brother joined the call. His brother agreed to hold the current bottle from tonight and give Ray one day's dose at a time, and on Sunday to drive with Ray to the apartment, take the rifle to his own home until the three of them review it together, and take the leftover tablets to a pharmacy take-back. Crisis numbers: 988 (call, text or chat), 911, and the county mobile crisis line for the brother's address. Consultation: phone consultation with a peer consultant at 5:30 PM; agreed with the plan and suggested a medication evaluation. Contact with others: brother, during the session, with the client's verbal consent; release of information signed today for his primary care physician.

Step 5, follow-up. Check-in call Saturday at 11 AM, documented as a separate contact note. Next session moved up to Tuesday 10/28 by video, then twice a week for two weeks. Means check: on Saturday, ask Ray, and with his consent his brother, who holds the bottle; on Tuesday, whether the rifle and leftover tablets have left the apartment. Therapist will call his primary care physician by Monday about his pain medication supply and drinking, and will call a psychiatrist's office with Ray on Tuesday to book a medication evaluation. Reassess at every contact. If the Saturday call goes unanswered: call twice more within the hour, then his brother, then the county mobile crisis line.

Why this note works:

Follow-up after a SAFE-T assessment

The assessment is a snapshot. What happens over the next weeks matters as much:

What suicide risk assessment can't do

Two meta-analyses explain why SAFE-T asks for judgment and not a score.

What that means for how you use the card:

For evidence on screening scales, and on guidance that rejects risk levels for treatment decisions, see the limits section of our C-SSRS screener guide.

How this works in TranqBay

TranqBay is practice software for therapists in private practice: a practice website, online booking, video sessions, session notes and client forms in one place. Here is where a SAFE-T assessment fits:

Before you set anything up, practice.tranqbay.health shows a sample practice website and what a client sees after booking a video consultation, including the reminders to find a private space and check their camera and mic before the call.

Frequently asked questions about the SAFE-T

Before your next session

If you're setting up a practice where clients book and join video sessions online, start at practice.tranqbay.health: you can see a sample practice website, the designs to choose from and what a client sees after booking, before you set up your own. You can also read more about running your practice with TranqBay.

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