10. I do not have suicidal thoughts.

SRA
Instructions
We realize what a difficult time this is for you.
Nevertheless, we need more information so we
can fully understand the extent of the problems
you have been struggling with.
All questions in this questionnaire should be
answered. These results are confidential. Do
not skip any questions. Your cooperation in
completing this questionnaire is appreciated.
Anticipate approximately 20 to 25 minutes to
complete.
You May Begin.
Section 1
Answer the following questions True or False.
When a statement is true, put an X under T for True.
When a statement is false, put an X under F for
False on your answer sheet.
1. There are times when I worry about what other
people think, or say about me.
2. In the last year, using drugs has been a problem
for me.
3. I have shared my suicidal intentions (verbally
or in writing) with another (or others)
4. It bothers me, when I am overlooked or ignored
by people I know.
5. People tell me I seem to be troubled, worked
up, or preoccupied much of the time.
6. My family has a history of suicide.

11. I have been offended and hurt by what

someone said about me.
12. My anxieties, worries, and apprehensions have
significantly reduced my social, occupational,
and recreational functioning.
13. My suicidal thoughts lack specific information
and details. They are rudimentary and
incomplete.
14. I occasionally think about suicide, but my
suicidal thoughts arent very strong or specific
(detailed), and dont last long.
15. There are times when I get angry and upset at
myself.
16. I use and, sometimes, abuse drugs.
17. I was recently (within the last year) discharged
or released from a psychiatric unit, in a
hospital.
18. My suicidal thoughts are rather blas, or
uninteresting, as they dont provide specific
information or details.
19. There are times when I am down, depressed,
and discouraged.
20. I have no fun, enjoyment, or joy in my life
anymore.
21. Suicidal thinking has emerged. However, there
is an absence of any specific suicide
information, plans, or details.
22. I have become a hardship, or burden, on people
close to me.
23. To be honest, I fear suicide and death.

7. Sometimes, I have morbid ruminations about

death and dying, but they arent suicidal
thoughts.

24. Although my frequent, intense, and enduring

suicidal thoughts include my suicidal intentions
and plans, I have not shared them (verbally or
in writing) with anyone.

8. I have said or done things, when angry or mad,

that I regret.

25. Even though I am not on a weight program, I

have lost (or gained) a lot of weight.

9. My drinking is more than just a little, or minor

problem.

26. I have access to a lethal suicide method (gun,

pills, car, rope, etc.) for killing myself.
27. My serious health problems have resulted in
my loss of mobility (ability to walk or drive)
and independence.
28. I have been influenced by a friend (or friends)
to do something I knew was wrong.

42. More specific suicidal thoughts are emerging.

In other words, I am beginning to think about
how I will kill myself. That said, I have not
discussed (either in writing or verbally) my
suicidal intentions.
43. I feel as if I am alone, emotionally isolated, and
do not fit in anymore.

29. It is very difficult for me to control or reduce

my worries and anxieties.

44. I worry excessively about a number of routine,

everyday activities like work, school, social
activities, etc.

30. I often take substances (alcohol/drugs) in larger

amounts, or over a longer period, than I
intended.

45. Even though, I may not show it, I usually

become defensive and/or upset, when someone
criticizes me in front of others.

31. I have no suicidal intentions.

46.

32. I am depressed (unhappy, sad, or discouraged)

nearly everyday.

47. My repeated substance (alcohol/drug) use has

resulted in my failing to fulfill important duties
and responsibilities at home, school, or work.

33. My relationship with my significant other has ended

(separation, divorce or death).

I often have muscle tension or strain.

34. I have been embarrassed and concerned about

mistakes I made.

48. My frequent, suicidal thoughts have low, or

weak, intensities and durations. Yet, they
contain some, albeit elementary, suicide plan
details.

35. My frequent, suicidal thoughts have low

intensities and short exposure times. They
have some (or very few), suicide plan thoughts,
but do not have any suicidal intentions.

49. There have been times, when I have known my

family (parents, guardian or spouse) did not
want me to do something but, I did it
anyway.

36. Drinking has interfered with my happiness and

success in life.

50. I have had a persistent depression (depressed

mood) on and off (mostly on) for two years, or
longer.

37. I often feel shaky, jittery, or trembling inside.

38. I spend a lot of time getting alcohol and/or
drugs, using them, and recovering from their
effects.
39. I do not always tell the whole truth when asked
about my personal life (e.g., my relationships,
sex, or finances).
40. Since I have been depressed, my interest and
pleasure, in almost all of the activities I used to
enjoy, have greatly diminished.
41. I have lied about my use of drugs either
saying I use less than I really do, or hiding the
fact that I use drugs at all.

51. I continue my substance (alcohol/drug) use,

despite the recurrent social and interpersonal
problems this causes.
52. I am considering several different methods for
committing suicide, or killing myself.
53. There are times when I really worry about
myself, my responsibilities and my happiness.
54. Others have noticed that its difficult for me to
concentrate, stay focused or sustain my
attention
55. I have experienced severe and uncompromising
feelings of hopelessness, for a long time.

56. My suicidal thoughts are frequent, intense

(strong or insistent) and, enduring or persistent.
In addition, specific suicide plans have
emerged. Yet, I have not told anybody about
my suicidal intentions.

69. My suicidal thoughts have acquired a coercive

sense of urgency, insistence and finality.
70. Almost all of my normal daily activities are
associated with, or affected by, my substance
(alcohol/drug) use.

57. I have given up, or significantly reduced,

important social, occupational, or recreational
activities, because of my substance
(alcohol/drug) use, or abuse.

71. The specificity (details) of my suicidal thinking

and plans, when combined with my stated
(written or verbal) suicidal intentions, depicts,
or defines, my high (severe) level of suicide
risk.

58. Although I deny my suicidal intentions, I have

completed some suicide preparations, like
deciding upon where or how.

72. There are times when I am concerned that

others may think badly of me.

59. I regret some of the things I have said or done

when I was angry or mad.

73. The frequency, duration and seriousness, of my

suicidal thoughts, are increasing.

60. I have completed some preparatory suicide

tasks, like giving away some of my
possessions, putting my affairs in order and, in
my own way, saying goodbye.

74. In my suicide plan, I have taken steps to

prevent discovery, and block rescue attempts.

61. Even though I am aware of the harmful effects

of repeated substance (alcohol/drug) use, I
continue to drink and/or use nonprescription
drugs.
62. There are times when I get very frustrated and
angry.
63. My fear of suicide and dying is decreasing.
64. There are times when I daydream about being
rich or famous.
65. Two or more of the following apply to me
(answer True or False on your answer sheet):
a. Depressed mood.
b. Feeling hopeless.
c. Loss of energy, fatigue.
d. Feeling worthless.
e. Diminished interest and pleasure in
everyday activities.
66. I continue using substances (alcohol/drugs)
even though I know they cause physical and
psychological problems for me.
67. I have chosen a method for committing suicide
that is available, accessible and lethal.
68. I am concerned about disapproval from others.

75. People tell me I am an irritable and anxious

person.
76. I am experiencing excessive, or extreme
anxiety and worry.
77. There have been times when I lied to my
parents, significant other, or spouse.
78. My suicidal thoughts are frequent, intense, and
enduring. They contain some specific suicide
plan information. Nevertheless, I have not
discussed my suicide plans or intentions with
anyone.
79. There have been times when I have been
resentful or jealous of another.
80. I have called a suicide hotline, or suicide
emergency service for help.
81. My suicidal intentions have greatly increased.
82. I have discussed (verbally, or in notes or
letters) my suicidal intentions with another
(others).
83. In my last suicide attempt, I sincerely believed
my method would work and I would die.
84. Sometimes I think about how my suicide will
affect people I know.
85. My intention to commit suicide is increasing
and becoming stronger every day.

Section 2
Select the answer to each of the following statements
that is accurate for you. Put an X under the number
(1, 2, 3, 4 or 5) that applies to you now.
86. With regard to your suicidal thoughts, select
the answer that is most accurate for you.
1. I dont think or talk about suicide.
2. My suicidal thoughts are infrequent and, of
low intensity and short duration.
3. My frequent suicidal thoughts have limited
intensities and short durations.
4. I do not discuss my frequent, intense and
enduring suicidal thoughts with anyone.
5. I have discussed my suicidal thoughts with
another (doctor, counselor, friend or close
relative).
87. My intention to kill myself is:
1. Diminishing and weakening.
2. Unchangeable or unalterable.
3. Increasing and getting stronger.
4. Accelerating rapidly.
5. I do not intend to kill myself.
88. Prior to this assessment, I have been diagnosed
as having (select one):
1. A personality disorder.
2. An alcohol (drinking) problem.
3. A drug problem.
4. All of the above (1, 2 and 3).
5. None of the above.
89. The following support system is available to
me (select one):
1. Doctor, therapist or counselor.
2. Social (family/friends) support.
3. Support group meetings.
4. All of the above (1, 2 and 3).
5. None of the above.
90. Within the last six years, I have been
diagnosed with, or treated for (select one):
1. Depression.
2. A bipolar disorder.
3. Schizophrenia.
4. All of the above (1, 2 and 3).
5. None of the above.

91. Rate your drinking on a ten-point scale. One

represents no drinking problem, and ten
represents a severe drinking problem. I rate
my drinking as::
1. No drinking problem (rate 1).
2. Responsible social drinker (rate 2 or 3).
3. A mild drinking problem (rate 4, 5 or 6).
4. A drinking problem (rate 7, 8 or 9).
5. A severe drinking problem (rate 10).
92. Within the last year, I have had intense urges
or cravings, for my substance of choice:
1. In settings where I had used the substance.
2. Randomly, at different times and places.
3. With people that offer me alcohol/drugs.
4. All of the above (1, 2 and 3).
5. None of the above.
93. How would you describe your drug use?
1. A serious problem.
2. A problem.
3. A moderate problem.
4. A mild or slight problem.
5. Not a problem.
94. My repeated substance (alcohol/drug) use has
resulted in:
1. My absences/poor performance at school or
work.
2. My neglecting household duties or
responsibilities.
3. Neglecting children in my home.
4. All of the above (1, 2 and 3).
5. None of the above.
95. How often do you think about killing yourself?
1. Constantly.
2. Several times a day.
3. Almost everyday.
4. Occasionally.
5. I dont think about killing myself.

96. Rate your anxiety on a ten-point scale. One

represents "no anxiety and, ten represents
severe anxiety. I rate my anxiety as:
1. No anxiety (rate 1).
2. Mild anxiety (rate 2, 3 or 4).
3. Moderate anxiety (rate 5, 6 or 7).
4. An anxiety problem (rate 8 or 9).
5. A severe anxiety problem (rate 10).
97. My sexual gender orientation or lifestyle is:
1. Gay.
2. Lesbian.
3. Transgender.
4. Bisexual.
5. Heterosexual.
98. Rate the severity of your suicidal thoughts.
1. No suicidal thoughts.
2. Weak suicidal thoughts.
3. Moderate suicidal thoughts.
4. Severe/uncompromising thoughts.
5. Extremely severe suicidal thoughts.
99. How many times have you attempted to
commit suicide, or kill yourself?
1. Once.
2. Two or three times.
3. Four or five times.
4. Six or more times.
5. I have not attempted suicide.
100. How long do your suicidal thoughts last?
1. A few seconds.
2. Minutes.
3. Hours.
4. All of the above (1, 2 and 3).
5. None of the above.
101. Rate your drug use on a ten-point scale. One
represents no drug problem, and ten
represents a severe drug problem. I rate my
drug use as:
1. No drug problem (rate 1).
2. A mild drug problem (rate 2, 3 or 4).
3. A moderate drug problem (rate 5, 6 or 7).
4. A drug problem (rate 8 or 9).
5. A severe drug problem (rate 10).

102. I have noticed, within the last year:

1. I use a lot more alcohol and/or drugs to get
intoxicated or high.
2. I do not get intoxicated or high, when I use
the same amount of alcohol or drugs that I
used to use.
3. My tolerance for alcohol/drugs has
noticeably increased.
4. All of the above (1, 2 and 3).
5. None of the above.
103. How would you describe your drinking?
1. A serious problem.
2. A problem.
3. A moderate problem.
4. A mild or slight problem.
5. Not a problem.
104. How would you describe your self-control? I have:
1. Good self-control.
2. Adequate self-control.
3. Below average self-control.
4. Poor self-control.
5. Very poor self-control.
105. Rate your satisfaction or dissatisfaction
with your life. Select the statement that is
most accurate for you. I rate my satisfaction
with my life as:
1. Very satisfied.
2. Satisfied.
3. Dissatisfied.
4. Very dissatisfied.
5. Extremely dissatisfied.
106. I have had withdrawal symptoms, like trouble
sleeping, tremors, sweating, nausea, vomiting,
headaches, etc.:
1. After reducing my alcohol use.
2. After reducing my drug use.
3. When I stopped my alcohol/drug use.
4. All of the above (1, 2 and 3).
5. None of the above.

107. My depressed mood has been:

1. Present for two or more years.
2. Symptom free for no longer than two month
intervals.
3. Varies between problematic (trouble-some)
and severe depression.
4. All of the above (1, 2 and 3).
5. None of the above.
108. I have recently experienced the following
significant loss (select one):
1. Severe health problem.
2. Independence (mobility).
3. Financial loss.
4. Significant other.
5. None of the above.
109. My reason for living (select one) is my:
1. Religion.
2. Children (or grandchildren).
3. Spouse or significant other.
4. All of the above (1, 2 and 3).
5. None of the above.
110. Rate your level of depression, on a ten-point
scale. One represents "no depression and ten
represents a severe depression. I rate my
depression as:
1. No depression (rate 1).
2. Some depression (rate 2, 3 or 4).
3. Depressed (rate 5, 6 or 7).
4. Very depressed (rate 8 or 9).
5. Severe depression (rate 10).
111. I have tried, but I cannot:
1. Reduce/cut down my alcohol/drug use.
2. Control my alcohol/drug use.
3. Stop using alcohol and/or drugs.
4. All of the above (1, 2 and 3).
5. None of the above.

112. With regard to your suicide plan(s), select the

statement that is most accurate for you.
1. I do not have a suicide plan.
2. I have suicidal thoughts, but no suicide
plans.
3. My suicide plan is basic and is not
complete.
4. My suicide plan is specific and complete, but I
havent discussed it with anyone.
5. I have discussed my suicide plan(s) with
my therapist, a close friend or a family
member.
113. Rate your feelings of hopelessness on a tenpoint scale. One represents hopelessness,
and ten represents extreme hopelessness. I
rate my feelings of hopelessness as:
1. Hopeful (rate 1 or 2).
2. Have some hope (rate 3 or 4).
3. Have little hope (rate 5 or 6).
4. Have no hope (rate 7 or 8).
5. Extreme hopelessness (rate 9 or10).
114. In my last suicide attempt, I (select one):
1. Was injured.
2. Needed medical care.
3. Was admitted to a hospital.
4. Was put on suicide watch.
5. None of the above.
115. In my present suicide plan, I:
1. Have taken steps to prevent discovery.
2. Prepared extensively for my death.
3. Scheduled and picked a location.
4. All of the above (1, 2 and 3).
5. None of the above.
116. I have discussed my suicidal intentions with
(select one):
1. My minister, priest, or rabbi.
2. My doctor, psychologist, therapist or
counselor.
3. A family member, friend, confidante, or
suicide hotline staff-person.
4. All of the above (1, 2 and 3).
5. None of the above.

117. With regard to my suicidal status, or state of

affairs:
1. My symptom clusters (depression, anxiety,
substance [alcohol/drug] use, etc.) have
escalated, or greatly increased.
2. My protective factors (social support, etc.)
have greatly deteriorated and, my risk factors
(significant loss, relationship problems, etc.)
have greatly increased.
3. I have discussed (verbally or in a note or letter)
my suicidal intentions with another.
4. All of the above (1, 2 and 3).
5. None of the above.
118. It is my honest opinion, that my suicide risk is:
1. No suicide risk.
2. Some, or mild suicide risk.
3. Moderate suicide risk.
4. High suicide risk.
5. Very high suicide risk.

Section 3
Rate each statement as it applies to you now. Put
an X on your answer sheet, under the number that
you select for your answer. Use the following
rating scale.
1. Rare or Never
2. Sometimes

3. Often
4. Very Often or Always

122. Exercise/Physical activity

123. Difficulty with others /Conflict
124. Adaptable/Adjustable
125. Worried/Anxious
126. Emotionally upset/Crying
127. Accepting/Friendly/Cooperative
128. Depressed/Discouraged
129. Difficulty Concentrating

119. With regard to abuse (mistreatment), I have

been severely abused:
1. Sexually.
2. Physically.
3. Emotionally.
4. All of the above (1, 2 and 3).
5. None of the above.
120. Select the answer that is most accurate for you.
During the last six months I have been:
1. Dangerous to myself (suicidal).
2. Dangerous to others (homicidal).
3. Both 1 and 2 (suicidal & homicidal).
4. Extremely suicidal.
5. None of the above.
121. I have prepared (put my affairs in order) for
my suicide, I have:
1. Written a note or letter.
2. Established my suicide plan.
3. Rehearsed my suicide.
4. All of the above.
5. None of the above.

130. Positive attitude/Outlook

131. Able to handle lifes problems
132. Self-reliant/Independent
133. Satisfied with Self/Like Self
134. Admit my errors/Mistakes
135. Nervous/Unable to relax
136. Good sense of humor/Laugh
137. Angry/Hostile with others
138. Poor self-control
139. Impulsive/Spontaneous
140. Insomnia/Trouble sleeping
141. Fatigued/Loss of energy
142. Drinking/Alcohol
v72.414

SRA
First Name: ____________________ Middle Initial: ________ Last Name: ___________________________
Last Four Digits of Your Social Security Number: ___ ___ ___ ___ Date of Birth:_____________________
(Month / Day / Year)

Age: ______

Sex:_________________

Marital Status: ______________________________________

(Single, Married, Divorced, Separated, Widowed)

Ethnicity (Race):______________________

Education (Highest Grade Completed): ___________________

I hereby agree to answer all statements truthfully. The information provided on this SRS answer sheet is
true, correct, and accurate.
____________________________________________________
_____________________
Client Signature

Date

Please complete the following: Yes = Y or No = N.

1. I have a serious alcohol problem: .........Y___ N___
4. I am severely depressed: ......................Y___ N___
2. I have a serious drug problem:..............Y___ N___
5. At this time, I am suicidal: .................Y___ N___
3. I am very anxious & apprehensive: ......Y___ N___
6. Number of times I have attempted suicide: ______
Section 1
If a statement is true put an X under T for True.
T
F
T
1. _____ _____
22. _____
2. _____ _____
23. _____
3. _____ _____
24. _____
4. _____ _____
25. _____
5. _____ _____
26. _____
6. _____ _____
27. _____
7. _____ _____
28. _____
8. _____ _____
29. _____
9. _____ _____
30. _____
10. _____ _____
31. _____
11. _____ _____
32. _____
12. _____ _____
33. _____
13. _____ _____
34. _____
14. _____ _____
35. _____
15. _____ _____
36. _____
16. _____ _____
37. _____
17. _____ _____
38. _____
18. _____ _____
39. _____
19. _____ _____
40. _____
20. _____ _____
41. _____
21. _____ _____
42. _____

If a statement is false put an X under F for False.

F
T
F
T
_____
43. _____ _____
64. _____
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44. _____ _____
65. _____
_____
45. _____ _____
66. _____
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46. _____ _____
67. _____
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47. _____ _____
68. _____
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48. _____ _____
69. _____
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49. _____ _____
70. _____
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51. _____ _____
72. _____
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52. _____ _____
73. _____
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74. _____
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75. _____
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76. _____
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56. _____ _____
77. _____
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57. _____ _____
78. _____
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58. _____ _____
79. _____
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59. _____ _____
80. _____
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60. _____ _____
81. _____
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61. _____ _____
82. _____
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62. _____ _____
83. _____
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63. _____ _____
84. _____
85. _____

F
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Section 2
Select the answer to each of the following statements that is accurate for you. Put an X under the number
(1, 2, 3, 4 or 5) that applies to you now.
86.
87.
88.
89.
90.
91.
92.
93.
94.
95.
96.
97.
98.
99.
100.
101.
102.
103.

1
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2
____
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3
____
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4
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5
____
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104.
105.
106.
107.
108.
109.
110.
111.
112.
113.
114.
115.
116.
117.
118.
119.
120.
121.

1
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2
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3
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4
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5
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Section 3
Put an X on your answer sheet under the number that you select for your answer. Use the following rating
scale.
1. Rare or Never
122.
123.
124.
125.
126.
127.
128.
129.
130.
131.

1
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2. Sometimes
2
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3
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3. Often
4
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132.
133.
134.
135.
136.
137.
138.
139.
140.
141.
142.

4. Very Often or Always

1
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2
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3
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4
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v72.414