Compliance and documentation
A therapy risk assessment framework to use for documentation
Discover an effective framework for therapy risk assessment to enhance client safety evaluations, advance clinical decision-making, and improve documentation.
Few areas of therapy practice are more stress-inducing than risk assessment and documentation. As a therapist, I know that it can feel like high stakes — for the client, for their loved ones, and for a therapist’s licensure. Managing suicidal or homicidal risk requires great responsibility. These moments often arise abruptly and we must navigate them with calmness, compassion, and skill despite our own heightened stress.
After managing a risk situation, documentation becomes crucial as a clinical tool and a means of protection, both professionally and as it relates to clinical care. Specialized training and a solid framework can help us assess and document risk scenarios effectively. This in turn, can help us better fulfill our responsibility, reduce our stress, support our clients, and protect our liability.
Key takeaways
- Risk assessments are a structured clinical approach to determining a client’s likelihood to harm themselves, harm someone else, or be victimized. This involves evaluating risk history, warning signs, risk factors, and protective factors that help to inform the severity and immediacy of the risk. These assessments are intended to protect the client and the public, produce necessary safety planning measures, and guide further clinical decision making.
- Assessing for risk should be guided by compassion and clinical judgment while being thoroughly documented. It is essential to objectively document what was observed, assessed, and what interventions were applied. It serves as evidence of the care provided and the clinical decisions made.
- Good documentation is timely, captures the situation accurately, protects the therapist’s liability by noting their risk mitigation efforts, and serves as a clinical tool by supporting ongoing treatment and decision-making. The American Psychiatric Association reinforces this by stating, “Documenting an estimation of a patient’s suicide risk may improve a clinician’s decision-making about the patient’s diagnosis and treatment plan.”
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Understanding the foundations of therapy risk assessment
Most therapy begins with a biopsychosocial assessment. This is a broad assessment that looks at holistic factors in a client’s life in order to determine any mental health diagnoses, client strengths, and a treatment plan for mental health symptoms. Risk assessment should overlap and is often done as part of the initial assessment, but should be conducted, documented, and revisited throughout treatment as indicated. Risk assessment has a much narrower focus of determining the client’s likelihood to harm themselves or someone else. This form of assessment involves an even higher degree of meticulous methodology, given the severity of potential outcomes. Ignorance of a detailed risk assessment process can mean that risk factors and imminent harm are missed or not treated properly, potentially leading to very detrimental outcomes.
On Headway, your intake note templates include a section for risk assessments. It can also be helpful to use a screening tool like the C-SSRS to identify risk. If risk is identified, further assessment and safety planning is required.
In the 1970s, risk evaluations focused mostly on how dangerous a client might be. These evaluations at the time were often subjective, not standardized, and lacked predictive ability. Since this time, structured assessment tools have helped to bring more objective measurement. Current practice guidelines recommend using clinical judgment in combination with structured assessment. This combination can help to create more effective outcomes and a more tailored and collaborative approach to risk prevention.
The five essential components of effective risk frameworks
A solid risk assessment framework has five key parts that all work together. Identification, analysis, evaluation, treatment planning, and monitoring make up this interconnected process. Let’s break them down.
1. Identification: This is the first level of information-gathering and starts to detect risk factors and protective factors. Direct questions, review of notes or intake paperwork, and clinical observations are helpful approaches in this phase. According to this research-based method, there are some key questions that can be answered with each component. The focus with identification is to answer the question, “What might happen?”
2. Analysis: This next component examines the identified risk factors. It looks at the nature, causes, and contributing factors. This is where a clinician can really start to look at the severity and immediacy of the risk. Validated assessment tools are often used, such as the Columbia Suicide Severity Rating Scale (C-SSRS), Patient Health Questionnaire-9 (PHQ-9), or Historical, Clinical, Risk Management-20 (HCR-20). The goal here is to answer the question, “What is the level of risk?” This relates to understanding what could happen and how likely it is to happen.
3. Evaluation: This component looks at all data that has been gathered to determine, “Is there a need for action?” Evaluation guides the next steps that will be taken in the process. Risk appraisal can be conducted here. Once you’ve looked at the whole picture and determined the severity and immediacy of risk, it will inform what comes next for risk management. If there is difficulty with evaluation, consultation with a supervisor or peers can be utilized and documented to provide better clarity.
4. Treatment planning: Here is where you answer how to actually manage the identified risks. It is recommended that clients work with therapists as much as possible to develop a treatment plan tailored to their risk profile.
Depending on the severity of the risk, things that can be included in a safety plan include hospitalization plans, identification of warning signs, coping strategies, emergency contacts, protective factors, and social support that the client can engage with. Collaboratively developing a plan with the client can help organize action steps that can give them alternative options instead of their risk behavior.
While managing safety risk and improving symptoms of depression or feelings of hopelessness, adhering to your client’s safety plan should be included in an overall treatment plan. Developing a safety plan is separate — and important; it’s something the client can take with them and refer to as needed in between sessions.
5. Monitoring: Risk factors and severity levels can fluctuate, so consistent and ongoing assessment can be useful to track with the client. Ongoing discussions, reapplication of validated assessments, documentation updates, and adjustments to safety and treatment plans can all be useful aspects of monitoring.
These components are all interconnected and flow nicely into one another. Monitoring may point to a need to return to one of the other components.
Documentation best practices for risk assessments
As you work through risk assessment and management with your clients, it is essential that detailed documentation reflects all relevant clinical information and action. Too often, risk assessment can be omitted from documentation, creating a greater risk for audits, claim denials, or legal liability. In both intake notes and ongoing progress notes, it is critical to accurately detail the reasoning for risk assessment, risk factors identified, assessment tools employed, client’s mental status, details of risk management or safety plans, rationale for clinical decisions, updated assessment data, changes in risk status, and changes in intervention plans. Utilizing direct client quotes can be useful to capture their thoughts, plans, and intent around the area of risk.
This detailed level of documentation protects clients by keeping an accurate record of client status and interventions. All providers on the client’s care team can use this as a reference to continue pursuing client safety. It protects the therapist by proving that they had clinically sound rationale and took appropriate steps of action. This reduces therapists’ risk for malpractice and legal liability as well as supports the therapist in case of any audits or reviews. The Los Angeles County Psychological Association states that “Preparing and maintaining clinical notes provides evidence of the standard of care and that the risk of legal or ethical violations has been managed. Informed consent, documentation and consultation are three strategies to ensure protection of both patient and therapist.”
Navigating ethical and legal considerations in risk assessment
Ethical guidelines and legal standards are central to the risk assessment process. While each professional governing body (LCSW, LMFT, etc) has their own set of ethical codes, there are some relevant overlapping ethics that have been distilled down in Tom Beauchamp and James Childress’ book, The Principles of Biomedical Ethics. These principles include autonomy, beneficence, nonmaleficence, and justice. They can be summarized within risk assessment as honest communication, collaboration with the client as much as possible, providing informed consent, respecting client choices, avoiding harm, ensuring fairness and objectivity, acting in the client’s best interests, and maintaining confidentiality as much as is legally allowed.
State laws of the client’s home residence dictate much of the legal requirements for therapists. In most states, specific risk situations mandate a break from confidentiality through mandatory reporting or involuntary hospitalization. Examples might include an imminent suicide attempt, duty to warn others of harm, and abuse or neglect to a minor or elder. In these situations, the ethical principle of confidentiality is overridden by the law in order to protect the greater good. It is essential to be informed of the pertinent state laws as the reporting requirements and criteria can vary. Since reporting requirements vary by state, therapists must be familiar with the relevant laws in their jurisdiction.
The American Academy of Pediatrics and American Psychological Association recommends that these limitations to confidentiality be discussed through informed consent before any risk assessment would ever happen. If there is ever uncertainty about reporting, it is recommended to consult with other therapists, your licensing board, or legal counsel and document those consultations.
Recognizing historical risk factors in client assessment
The Veteran’s Administration and CDC publications on suicide and youth violence identify some key risk factors to watch for: current thoughts of self-harm or harming others, current intent to harm self or others, specific plans with access to means, a history of previous suicide attempts or violent behavior, active substance use, diagnosed mental health conditions, impulsivity, mood changes, social isolation, major life stressors, feelings of hopelessness or aggression, trauma history, or psychotic symptoms.
It is recommended that these be assessed holistically, not as a simple checklist, using clinical judgment to weight reported factors — and that validated assessment tools are used to assist. Past history of these behaviors can be predictive of more, but that is not necessarily the case for all clients. When trying to support clients, however, it can be important to not shame them or add to stigma about their past actions. Therapists should continue to be a support with positive regard for their clients no matter the history.
As the client’s risk factors are identified, the next step is to match those with appropriate interventions. Ensuring safety, stabilization, and making tangible plans are often the first necessary interventions. Focusing on the development of protective factors is recommended by the CDC. This can include personal factors of building coping skills, awareness of resources (internal and external), and a focus on reasons for living.
DBT, CBT, and mindfulness are examples of some great interventions for this purpose. Helping clients connect to supportive relationships whether through family, friends, or support groups can be highly effective. DBT and solution-focused therapy can work well for this purpose. Community supports and resources are also another helpful protective factor to build with clients. These can be cultural or religious groups the client affiliates with, or helping connect clients to resources that can help them manage stressors and meet their needs (e.g. food stamps, low cost health clinics for prescriptions, job resources).
Implement evidence-based assessment tools in your practice
As previously mentioned, assessment tools that are backed by research can add helpful information to the risk assessment process. They can also be helpful for limiting liability as they are considered best practice for developing a defensible rationale. Some of the most commonly used evidence-based tools are the PHQ-9, the C-SSRS and the Beck Scale for Suicide Ideation (BSI) for suicide risk. For violent or homicidal risk, the HCR-20 or Brief Violence Checklist (BVC) can be applied. For risk situations involving potential victimhood, the Danger Assessment (DA) for intimate partner violence, the Childhood Trauma Questionnaire, or Elder Abuse Suspicion Index (EASI) could be applied. These should be applied as soon as risk is identified and ongoing application can be part of ongoing monitoring at an appropriate cadence.
The first level of determining which assessment to use simply depends on the type of risk that is uncovered through identification. Suicidal, homicidal, violence, abuse, or neglect risk necessitate the relevant options. The depth of assessment and information required will also determine the assessment. Many assessments are built into Headway’s platform, making it easy for you to administer them and for your clients to complete them.
- The PHQ-9 is a brief depression screen that incorporates a question about suicide. This is helpful as a brief assessment in outpatient or primary care settings that can trigger if there is more assessment that needs to be done.
- The C-SSRS is also a brief assessment, but it focuses specifically on suicidality. It captures a wide variety of suicidal thoughts and behaviors. The assessment provides standardization to suicide risk assessment. This tool can be used in outpatient, inpatient, primary care, and emergency departments.
- The BSI is a more intensive questionnaire that can provide a high level of sensitivity to suicidal severity. Because the assessment has some higher complexity, it can require more training. It is useful in a variety of inpatient and outpatient settings who have already reported suicidal ideation.
- The HCR-20 is the gold standard of assessment for violence. It offers a high amount of data. This is an intensive assessment that requires some clinical training to administer. It is best suited for forensic, inpatient, high-risk outpatient, and mandated evaluations. It is not as useful for brief, acute assessments.
- The BVC is a very brief screen that can help monitor imminent violence risk. It is best used in higher risk settings such as inpatient and emergency departments.
- The DA is a weighted assessment that focuses on the potential of intimate partner violence and homicide. Emergency departments and domestic violence shelters are common places that utilize this assessment, but it can be used in a variety of clinical settings.
Assessing specific cultural understandings of components of mental health, risk, and stigma, can be helpful for understanding adaptations. Some of these assessments, such as the PHQ-9 and C-SSRS, have been validated in other languages that can be utilized. Where alternate languages don’t exist, using a translator proficient with mental health concepts can be useful. It is important to use a culturally sensitive, trauma-informed approach when approaching complex topics of risk.
According to the APA, there are some limitations to precisely how predictive assessment tools can be of risk, so it is important that the tools are not solely relied upon. They should be a part of the overall clinical picture, but not utilized as a replacement for clinical judgment.
Telehealth adaptations for remote risk assessment
Risk assessment conducted via telehealth can provide challenges for observing non-verbal cues and managing crisis situations. Disconnection from local resources can provide a challenge as well. Telehealth provides opportunities for increased access and frequency of contact for monitoring. The American Psychiatric Association recommends that clinicians have awareness of local reporting laws, protocols in place for emergency situations, and connections to local resources that can help facilitate support in emergency situations.
Telehealth outpatient therapy is one of the lowest levels of care that can be offered. It can be important to provide informed consent around this and to determine other supports (e.g. Intensive outpatient group program) that can be added if necessary for clients who are at higher risk. Therapists should use their clinical judgment to determine if telehealth is appropriate for clients at elevated risk and be prepared to refer to higher levels of care when virtual sessions cannot adequately ensure safety. To safely conduct telehealth sessions, it is recommended that there is an emergency contact on file, a protocol in place in case the client telehealth call drops, and that in every session, the client’s physical location is discussed and noted.
Building a continuous improvement approach to risk assessment
The American Psychological Association guidelines state that assessment competence is not static, but requires ongoing, deliberate effort. This can come through continuing education, interactive workshops, supervised experience, and consultation with experts. Active learning methods such as role-play have shown to enhance risk assessment skills. Peer consultation can also be effective for maintaining and improving risk assessment skills. It can help to review difficult cases, receive feedback on assessment practices, and integrate new evidence.
Ongoing practice in real time with clients can continue to improve effectiveness. I have found after practicing this for years, it is much easier to remember the proper risk assessment steps I need to take in session. I have also learned how to manage my emotions that can arise when a client mentions risk situations. Instead of robotically running through a checklist that might make the client feel uncomfortable, I have learned to manage my own anxiety, keep the conversation natural, and still properly assess the situation. Familiarity is a great trainer for improving these skills.
Some helpful resources for ongoing trainings that can enhance skills include:
Headway helps you focus on being there for your clients
When facing a situation where risk is present, you need all of your focus to be on the assessment, management, and documentation of that risk. Headway offers practice management tools that can ease your administrative burden and allow you to devote your energy to helping clients through challenging moments. With assessments and documentation tools built right into the platform, you can navigate risk situations with less stress.
This content is for general informational and educational purposes only and does not constitute clinical, legal, financial, or professional advice. All decisions should be made at the discretion of the individual or organization, in consultation with qualified clinical, legal, or other appropriate professionals.
© 2025 Therapymatch, Inc. dba Headway. All rights reserved. No part of this publication may be reproduced without permission.
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