Clinical Template

Risk Assessment Template and Examples

Last updated: October 6, 2026

Reviewed by the WellNotes Clinical Team

Type or dictate your safety evaluation findings. Get a thorough risk assessment (risk factors, protective factors, safety plan, and recommendations) in minutes.

What is a Risk Assessment template?

A clinical risk assessment template documents risk factors, protective factors, the client's current status (ideation, plan, intent, means and behavior), a risk formulation, the safety plan and your recommendations. Record the questions asked and the client's answers, the level of risk you concluded and why, and the actions you took as a result.

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What is a Risk Assessment?

A risk assessment is a critical clinical document used to evaluate a client's risk for self-harm, suicidal behavior, or violence toward others. Thorough risk documentation protects both clients and clinicians. It demonstrates clinical due diligence and guides safety planning decisions.

The risk assessment format examines the full clinical picture: identifying risk factors that elevate concern, protective factors that mitigate risk, the client's current status and level of intent, a concrete safety plan, and clinical recommendations for ongoing management. This comprehensive structure ensures no critical element is overlooked during high-stakes clinical moments.

A risk assessment is the expected standard of care whenever a client presents with suicidal ideation, self-harm behaviors, homicidal ideation, or other safety concerns. Therapists, psychologists, counselors, social workers, and psychiatrists all benefit from being proficient in risk documentation. Proper risk assessment documentation is one of the most legally scrutinized areas of clinical practice.

Risk Assessment Template Structure

Use these 5 headings, in this order, for every risk assessment. Each card explains what belongs in the section.

Risk Factors

Identified factors that elevate the client's risk level: current ideation, prior attempts, access to means, substance use, recent losses, demographic risk factors, and psychiatric history.

Protective Factors

Factors that reduce the client's risk level: reasons for living, social support, treatment engagement, coping skills, religious beliefs, and responsibility to others.

Current Status

The client's present level of risk: current ideation (frequency, intensity, duration), presence or absence of plan, access to means, intent, and overall risk classification (low, moderate, high, imminent).

Safety Plan

A collaborative safety plan developed with the client: warning signs, internal coping strategies, people to contact for distraction, professionals to contact in crisis, and means restriction steps.

Recommendations

Clinical recommendations based on the risk assessment: level of care needed, treatment modifications, consultation plans, follow-up frequency, and documentation of clinical reasoning.

Risk Assessment Examples

3 filled examples for different sessions, written in the template above.

All examples are fictional and de-identified. They show structure and level of detail, not clinical advice for a real client.

Risk Assessment Example 1: Moderate risk (passive ideation)

Adult client with depression and a prior attempt, reporting recent passive suicidal ideation.

Risk Factors: Static risk factors: Prior suicide attempt (overdose, age 19, hospitalized). Family history of completed suicide (uncle). Male gender. Chronic pain condition. Dynamic risk factors: Current passive suicidal ideation ("sometimes I think everyone would be better off without me"). Recent divorce finalized 6 weeks ago. Increased alcohol use (from 2-3 drinks/week to daily drinking, 4-5 drinks). Social isolation: reports losing mutual friends in divorce. Insomnia (sleeping 3-4 hours/night). Recently prescribed sleep medication with access to 30-day supply. Job performance declining: received formal warning at work.
Protective Factors: Two children ages 8 and 11: client states "I could never do that to my kids." Active engagement in therapy (has not missed a session in 4 months). Willingness to discuss suicidal thoughts openly. No current plan or intent. Religious faith: describes suicide as "against my beliefs." One close friend who checks in regularly. Employed with health insurance. Future-oriented statements present ("when things get better"). Historically responsive to treatment: previous depressive episode resolved with therapy and medication.
Current Status: Risk classification: MODERATE. Client reports passive suicidal ideation occurring 2-3 times per week, typically in the evening when alone. Ideation is described as fleeting thoughts ("what's the point") lasting seconds to minutes. Denies active plan or intent. Denies rehearsal behaviors. Denies homicidal ideation. Reports ideation has increased over past 3 weeks coinciding with divorce finalization and increased alcohol use. Acknowledges access to means (sleep medication, 30-day supply). Affect is congruent: tearful when discussing children, flat when discussing future. Judgment is fair: agreed to safety planning and means restriction.
Safety Plan: 1. Warning signs: Feeling of "emptiness," increased urge to drink, cancelling plans with friends, not returning children's calls. 2. Internal coping: Go for a walk, call a close friend, play guitar, watch comedy, review photos of children. 3. Social contacts for distraction: Close friend (number on file), sister (number on file). 4. Professional contacts: therapist office (number on file), 988 Suicide & Crisis Lifeline, local crisis center. 5. Means restriction: Client agreed to give 30-day supply of sleep medication to a close friend, keeping only 3-day supply at home. Will remove alcohol from apartment. 6. Emergency: 911 or go to nearest emergency department. Client signed safety plan and received copy.
Recommendations: 1. Increase session frequency from biweekly to weekly. 2. Refer for psychiatric evaluation: medication management for depression and insomnia (non-lethal alternatives to current sleep medication). 3. Recommend substance abuse assessment given escalating alcohol use. 4. Verify means restriction completed by next session. 5. Consult with colleague Dr. Williams regarding level of care appropriateness. 6. Reassess risk at each session until stabilized. 7. If ideation becomes active (plan, intent, or timeline), coordinate immediate psychiatric evaluation for possible hospitalization. 8. Document: Clinical judgment supports outpatient treatment at this time given strong protective factors, absence of plan/intent, and client's active engagement in safety planning.

Risk Assessment Example 2: Low risk (routine screen with a positive item)

Adult client who endorsed item 9 on a routine PHQ-9.

Risk Factors: Endorsed PHQ-9 item 9 ("several days"). Current depressive symptoms, recent job stress. No prior attempts or self-harm. No family history of suicide reported. Alcohol: 2 drinks per week.
Protective Factors: Lives with spouse, describes relationship as supportive. Strong religious beliefs against suicide. Engaged in treatment and future oriented (planning a trip next month). Good problem-solving skills.
Current Status: On follow-up, client clarified the item reflected thoughts that "it would be easier to sleep for a week," not thoughts of death or suicide. Denies suicidal ideation, plan, intent or preparatory behavior. Denies HI. No firearms in the home.
Safety Plan: Reviewed warning signs and coping strategies. Client has crisis line number (988) saved in phone and agreed to contact the clinician or 988 if thoughts change.
Recommendations: Risk formulation: low acute risk. Continue weekly therapy and repeat PHQ-9 every 2 weeks. Re-screen if symptoms worsen.

Risk Assessment Example 3: Adolescent self-harm (non-suicidal)

15-year-old client who disclosed cutting during a scheduled session.

Risk Factors: Client disclosed superficial cutting on her forearm 3 times in the past 2 weeks, most recently 2 days ago, after conflict with peers online. History of depressive symptoms. Recent breakup. No prior suicide attempts reported. Denies substance use.
Protective Factors: Close relationship with her older sister. Engaged in soccer and wants to keep playing. Willing to talk about self-harm in session. Caregiver involved and supportive.
Current Status: Client describes cutting as a way to "feel something else for a minute" and denies suicidal intent. Denies current suicidal ideation, plan or intent, and denies HI. Wounds described as healing, no medical attention needed per client; nurse check offered. Access to means: razor blades from a pencil sharpener.
Safety Plan: Developed a written safety plan with client: warning signs (scrolling late at night after arguments), coping skills (ice cube, drawing, texting sister), adults to contact, crisis line 988 and text line. With client's knowledge and per policy, caregiver informed and agreed to secure sharp objects.
Recommendations: Risk formulation: non-suicidal self-injury with low to moderate acute suicide risk; continue to monitor. Increase to weekly sessions, add DBT-informed emotion regulation skills, reassess self-harm and suicide risk every session, and consult with supervisor (completed today).

Suicide risk assessment questions

Ask directly and in plain language, and record the questions and the client's answers. A typical sequence moves from general to specific:

Ideation: In the past few weeks, have you wished you were dead or that you could go to sleep and not wake up? Have you had thoughts of killing yourself?
Frequency and intensity: How often do these thoughts come? How long do they last? How hard are they to stop?
Plan: Have you thought about how you might do it? Have you thought about when or where?
Intent: Do you have any intention of acting on these thoughts?
Behavior: Have you ever tried to end your life, started to and stopped, or done anything to prepare?
Means: Do you have access to firearms, stored medications or other means you have thought about using?
Protective factors: What has kept you safe so far? What are your reasons for living?

Many settings use a validated instrument for screening. The NIMH Ask Suicide-Screening Questions (ASQ) toolkit is a four-question screen for medical settings, with a brief suicide safety assessment after a positive screen. The Columbia-Suicide Severity Rating Scale (C-SSRS) assesses ideation, behavior, and their severity and intensity. Use the official versions and follow your organization's protocol.

Safety planning after a risk assessment

When risk is present, the assessment usually ends with a collaborative safety plan: warning signs, coping strategies, people and places, professional and crisis contacts including the 988 Suicide and Crisis Lifeline, and steps to make the environment safer. In the risk assessment itself, summarize the plan and the means safety steps agreed. For the section-by-section structure of the Stanley-Brown format, a filled example and how to document it, see the safety plan template.

How to Write a Risk Assessment

Risk factors. List static and dynamic factors: prior attempts, current symptoms, substance use, recent losses, access to means and relevant history.
Protective factors. Record what reduces risk for this client: relationships, reasons for living, engagement in care, coping skills.
Current status. Document ideation, frequency, plan, intent, preparatory behavior and access to means, using the client's answers to direct questions.
Safety plan. Summarize the safety plan you developed with the client and the means safety steps agreed, and note where the full plan is kept.
Formulation and recommendations. State the risk level, the reasoning behind it, and the actions taken (frequency changes, referrals, consultation, follow-up).

Common Risk Assessment Mistakes

Writing "denies SI" with no record of what was asked or of follow-up questions after a positive screen.
Assigning a risk level without explaining the reasoning.
Leaving out access to lethal means.
Not documenting consultation, referrals or follow-up when risk is elevated.

How It Works

Three steps to a finished risk assessment

Describe the Assessment

Type or dictate your clinical findings: risk factors, protective factors, current status, and safety plan details. No special formatting needed.

WellNotes Structures Your Assessment

Your findings are organized into a proper risk assessment with risk factors, protective factors, current status, safety plan, and clinical recommendations.

Review, Edit, and Sign

Read through the assessment carefully, verify every detail, then export as PDF or copy to your EHR. Done.

Documentation Before & After WellNotes

Before WellNotes

A client just disclosed suicidal ideation. You spend the session assessing risk and building a safety plan. Now you need to document every detail (risk factors, protective factors, your clinical reasoning) under time pressure.

After WellNotes

Assessment complete. You dictate your findings. A structured risk assessment appears with risk factors, protective factors, safety plan, and recommendations, ready for careful review and sign-off.

From 30+ minutes to under 5

Who Uses Risk Assessment?

TherapistsPsychologistsCounselorsSocial WorkersPsychiatrists

Risk Assessment FAQ

How do you document suicide risk level in a progress note?

State the questions you asked and the client's answers about ideation, plan, intent, behavior and access to means, summarize key risk and protective factors, then give your risk formulation (for example low, moderate or high acute risk) with the reasoning and the actions you took. Follow your organization's policy and any required screening tool.

What is a risk assessment in therapy?

A risk assessment is a clinical document that evaluates a client's risk for self-harm, suicidal behavior, or violence toward others. It examines risk factors that elevate concern, protective factors that mitigate risk, the client's current level of intent and planning, a collaborative safety plan, and clinical recommendations for ongoing management.

When should a risk assessment be completed?

A risk assessment should be completed whenever a client presents with suicidal ideation, self-harm behaviors, homicidal ideation, or other safety concerns. It should also be conducted at intake, during crisis situations, when there are significant changes in the client's condition, and at regular intervals for clients with ongoing risk factors.

What should a safety plan include?

A thorough safety plan should include warning signs the client can recognize, internal coping strategies, people the client can contact for support, professional resources and crisis lines, means restriction steps, and emergency contacts. WellNotes helps structure all of these elements in a clear, organized format.

Is risk assessment documentation legally required?

Risk assessment documentation is one of the most legally scrutinized areas of clinical practice. While requirements vary by state and setting, thorough risk documentation demonstrates clinical due diligence and protects both clients and clinicians. Failure to properly assess and document risk is a leading cause of malpractice claims in mental health.

How do I document risk level?

Risk levels are typically classified as low, moderate, high, or imminent based on the balance of risk and protective factors, the presence or absence of a plan and intent, and access to means. WellNotes helps you organize your clinical findings into a structured assessment that clearly communicates the risk level and your clinical reasoning.

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