Screening Instruments & Safety PlanningC-SSRS · GAD-7 · PHQ-9
Three instruments you will use in nearly every intake and many sessions. This training covers what each measures, how to administer it, how to score it, how to document it, and — most importantly — what you do next.
What this page is, and how you are required to use it
This is required clinical training for every intern, practicum student, staff member, and associate under supervision at Orchard Human Services. It covers the three screening instruments you will use in nearly every intake — and the safety planning that follows when a screen comes back positive.
You may not administer these instruments with an Orchard client until you have completed this training and your clearance has been recorded by the Clinical Director. That is not a formality. These are the tools by which we find out whether someone in our care is in danger, and a screen administered badly is worse than no screen at all.
Work through it in this order
- Module 1 — C-SSRS & safety planning 90 minSuicide risk screening, the skip rule, risk levels, and the six-element Orchard Safety Plan. Then the 20-item assessment.
- Module 2 — GAD-7 30 minAnxiety screening, score bands, the unscored impairment item, documentation. Then the 15-item assessment.
- Module 3 — PHQ-9 40 minDepression screening, score bands, and the item 9 protocol that must never be skipped. Then the 15-item assessment.
- Get the forms 20 minDownload the printable PHQ-9 and GAD-7, get the C-SSRS from Columbia, complete their free training, and use the practice scorer.
- Log your hours and send the record 10 minGenerate your training record, then email it to the Clinical Director. Your training is not on file until it arrives.
How to engage with it. Read every module in full — do not skim to the assessment. Take each assessment when you finish its module, not all three at the end. Passing is 85%, and you may retake as often as you need. Read the explanation under every question, including the ones you got right.
Plan about four hours, and split it across sittings if that suits you better. Finish the Columbia certificate separately and bring it with your record. If anything here is unclear, ask before your next intake rather than after it.
Complete this training before you administer these instruments with any Orchard client
This is a competency requirement of the Orchard Human Services clinical training program. Interns, practicum students, staff, and associates under supervision must complete all three modules, pass all three assessments at 85% or above, and hold a current Columbia training certificate before administering these instruments with a client.
If you are unsure whether you have met this requirement, you have not. Check with the Clinical Director before your next intake.
Hold these regardless of setting or caseload
- A score is not a decision. These are screening instruments. They inform clinical judgment; they never replace it, and they never diagnose.
- You do not carry risk alone. Any positive suicide screen is discussed with your supervisor the same day. Not at your next scheduled supervision — the same day.
- Ask the question directly. Asking about suicide does not plant the idea. Not asking leaves the person alone with it.
If a client is in immediate danger, act first and document after.
Module 1 · Columbia-Suicide Severity Rating Scale
The C-SSRS
The Columbia-Suicide Severity Rating Scale is the most widely used suicide risk screening instrument in the world. Developed by Kelly Posner and colleagues at Columbia University with NIMH support, validated in The American Journal of Psychiatry (Posner et al., 2011), and available in more than one hundred languages.
You will hear it called the Columbia, the C-SSRS, or the Columbia Protocol. Note the full name: Columbia-Suicide Severity Rating Scale. Written correctly in your notes, it is C-SSRS.
It does not produce a score
Unlike the GAD-7 and PHQ-9, the C-SSRS yields no total number. It sorts responses into risk categories based on which questions were endorsed, not how many.
This matters for documentation. You never write “C-SSRS score of 3.” You write which items were endorsed and what risk level resulted.
Free training, and you must complete it
The instrument is free to use, but the developers require that administrators be trained. Free training is available at cssrs.columbia.edu. Complete it, save your certificate, and give a copy to your supervisor before you screen anyone.
Six questions, with a skip rule
The Screen Version has six questions. Questions 1 and 2 cover ideation. Questions 3 through 5 escalate through method, intent, and plan. Question 6 covers behavior.
If the client answers NO to question 2, skip directly to question 6. Questions 3 through 5 are only asked when question 2 is endorsed.
Interns frequently get this wrong in both directions — asking all six regardless, or stopping at question 2 and never asking about behavior. Always ask question 6. A person with no current ideation may still have a recent attempt.
Risk levels and what each requires
A safety plan is not optional
Any moderate or high risk determination requires a completed safety plan before the client leaves, plus same-day supervisor contact. If you cannot reach your supervisor, use the crisis pathway. Never end a session at moderate or high risk without a plan in the client’s hands.
The Orchard Safety Plan
A safety plan is a collaborative, written document created with the client, in the client’s own words. It is not a form you fill out about them, and it is not a no-suicide contract — contracts have no evidence base and offer no protection to anyone.
The approach here follows the evidence-based Safety Planning Intervention (Stanley & Brown, 2012), adapted for Orchard practice.
The six elements
Environmental safety
The Stanley-Brown protocol includes a step on reducing access to means of harm. This is the element with the strongest evidence behind it, and it is also the one requiring the most clinical care — it involves the client, and usually a family member, in practical decisions about the home environment.
Interns do not conduct this conversation alone. Raise it with your supervisor, who will determine how and whether it is addressed in this case and who should be present.
- Write it together, in their handwriting where possible. Ownership matters more than legibility.
- Their words, not clinical language. If they say “when I get in the hole,” the plan says when I get in the hole.
- Ask where it will live. A plan in a drawer is not a plan. Wallet, phone photo, refrigerator, bedside.
- Photograph it. They keep the original; a copy goes in the chart.
- Test it aloud. “It’s Tuesday at 2am and it’s bad. Walk me through what you do.” If they cannot narrate it, the plan is not usable yet.
- Revisit it. A safety plan is a living document, reviewed and revised, not filed and forgotten.
What goes in the note
- Instrument and version — “C-SSRS Screen Version administered.”
- Which items were endorsed — by number. Not a score.
- Client’s own words — quote the response to any endorsed item.
- Risk level determined and the reasoning behind it.
- Protective factors identified.
- Safety plan — completed or not, and if not, why.
- Supervisor consultation — name, time, and what was advised.
- Disposition — what happens next and when the next contact occurs.
Write it the same day. A risk note written three days later is worth very little clinically and nothing at all if it is ever reviewed.
Module 1 assessment
Twenty items covering administration, the skip rule, risk levels, safety planning, and documentation. Passing score 85% — 17 of 20. Retake as many times as you need. Your score carries into the training record automatically.
Module 2 · Generalized Anxiety Disorder 7-item scale
The GAD-7
A seven-item self-report measure of anxiety severity over the past two weeks, developed by Spitzer, Kroenke, Williams, and Löwe and published in Archives of Internal Medicine (2006). Free to use, no permission required, no fee.
Each item scores 0 to 3 — not at all, several days, more than half the days, nearly every day. Total range 0 to 21.
At a cut point of 10 or above, the GAD-7 shows sensitivity of 89% and specificity of 82% for generalized anxiety disorder. It also performs reasonably as a screen for panic disorder, social anxiety, and PTSD — which is useful, but means a high score tells you anxiety is present, not which anxiety.
Score bands
Item 8 is not scored
After the seven scored items there is a functional impairment question — how difficult have these problems made it to work, take care of things at home, or get along with others?
It is not part of the total, and it is often the most clinically useful line on the page. A score of 8 with “extremely difficult” impairment tells you far more than a score of 12 with “not difficult at all.” Always ask it, always document it.
How to give it well
What goes in the note
- “GAD-7 administered, total score X (severity band).”
- Functional impairment response from item 8, in the client’s words.
- Notable item-level responses — which symptoms are driving the score.
- Change from previous administration, if applicable.
- Clinical impression — how the score fits what you observed. If they diverge, say so.
- Administration method if read aloud or interpreted.
Never write “client has GAD.” The instrument screens; it does not diagnose, and interns do not diagnose.
- Scoring the impairment item into the total.
- Treating a score of 10 as a diagnosis.
- Administering only at intake and never again.
- Missing the client whose score is low because they have organized their entire life around avoiding anxiety triggers.
Module 2 assessment
Fifteen items covering scoring, bands, the impairment item, administration, and documentation. Passing score 85% — 13 of 15.
Module 3 · Patient Health Questionnaire-9
The PHQ-9
A nine-item self-report measure of depression severity over the past two weeks, developed by Kroenke, Spitzer, and Williams and published in the Journal of General Internal Medicine (2001). The nine items map directly onto the DSM criteria for major depressive disorder. Free to use.
Each item scores 0 to 3. Total range 0 to 27. At a cut point of 10 or above, sensitivity and specificity for major depression are both approximately 88%.
Score bands
Item 9
Any positive response to item 9 requires immediate follow-up
Item 9 asks about thoughts of being better off dead or of hurting oneself. Any response other than “not at all” — including “several days” — requires that you stop, ask directly, and follow up before the session ends.
Do not wait until you have finished scoring. Do not leave it for the next appointment. Do not assume a low total score means item 9 can be deferred. A client can score 6 overall and endorse item 9.
What you do: administer the C-SSRS, complete a safety plan if any risk is present, and contact your supervisor the same day. All three. Every time.
The most common serious error with the PHQ-9 is collecting the form, scoring it later, and finding item 9 endorsed after the client has gone home.
Build the habit now: look at item 9 before the client leaves the room. Every time, on every form, regardless of the total. It takes two seconds.
How to give it well
What goes in the note
- “PHQ-9 administered, total score X (severity band).”
- Item 9 response, explicitly stated — including when it is zero. Write “PHQ-9 item 9 endorsed at 0” or the actual value. Never leave it unaddressed in a risk-relevant note.
- If item 9 was positive: what you asked, what the client said in their own words, C-SSRS result, safety plan status, supervisor contacted with name and time.
- Functional impairment response.
- Somatic confound if medical illness may be inflating items 3, 4, 5, or 7.
- Change from previous administration.
- Scoring later and missing item 9.
- Writing “client denies SI” when item 9 was endorsed at 1 — those are contradictory and it will be noticed.
- Recording a diagnosis rather than a screening result.
- Attributing a somatically inflated score to depression without noting the medical picture.
Module 3 assessment
Fifteen items covering scoring, bands, item 9 protocol, somatic confounds, and documentation. Passing score 85% — 13 of 15.
Forms · Printable copies and practice scoring
Where forms live, and why it matters
Client data goes in TheraNest. Never on a webpage.
A fillable clinical form on a public website transmits protected health information to a server with no Business Associate Agreement. That is a HIPAA exposure, and it is entirely avoidable.
Real administration goes through TheraNest, which is covered, auditable, and already part of the record. Paper forms are scanned into the chart and the paper is destroyed per policy.
The scorer further down this page is a training tool only. It calculates in your own browser, transmits nothing, and stores nothing. Do not use it with client responses.
Download and print
Public domain — free to copy and use
Both were developed by Drs. Robert L. Spitzer, Janet B. W. Williams, and Kurt Kroenke under an educational grant from Pfizer Inc. No permission is required to reproduce, translate, display, or distribute them.
The versions below are Orchard-branded and formatted for clinic printing, with scoring keys on the reverse for staff use.
We do not host this one, and neither should you
The Columbia-Suicide Severity Rating Scale is copyright The Research Foundation for Mental Hygiene. It is free to use, but Columbia controls distribution, requires registration, and mandates training before administration.
Get it from the source, and complete the free training while you are there. Save your certificate and give a copy to your supervisor.
C-SSRS Self-Report Screener — Recent →
Columbia Lighthouse Project — forms and free training →
Scoring practice
Work through a form the way a client would, and watch the score and severity band update. Use it to build fluency with the bands before you are sitting with someone.
Nothing entered here is transmitted or saved. It computes in your browser and disappears when you close the page. Do not enter client responses.
PHQ-9
Over the last two weeks, how often have you been bothered by any of the following problems?
1Little interest or pleasure in doing things
2Feeling down, depressed, or hopeless
3Trouble falling or staying asleep, or sleeping too much
4Feeling tired or having little energy
5Poor appetite or overeating
6Feeling bad about yourself — or that you are a failure or have let yourself or your family down
7Trouble concentrating on things, such as reading the newspaper or watching television
8Moving or speaking so slowly that other people could have noticed? Or the opposite — being so fidgety or restless that you have been moving around a lot more than usual
9Thoughts that you would be better off dead or of hurting yourself in some way
GAD-7
Over the last two weeks, how often have you been bothered by the following problems?
1Feeling nervous, anxious, or on edge
2Not being able to stop or control worrying
3Worrying too much about different things
4Trouble relaxing
5Being so restless that it is hard to sit still
6Becoming easily annoyed or irritable
7Feeling afraid as if something awful might happen
Both instruments have an unscored functional impairment question after the numbered items: how difficult have these problems made it to do your work, take care of things at home, or get along with other people?
It is not in the total and it is often the most useful line on the page. Ask it. Document it in the client’s words.
Required training hours
Complete the fields below and generate your training record. It computes in your browser and is not stored anywhere — you download it, sign it, and submit it to the Clinical Director for countersignature and filing.
These hours count toward your directed experience
This is required clinical training within the Orchard Human Services program, necessary for competence and fitness to serve Orchard clients. The Clinical Director determines that these hours count toward your directed experience under your supervision contract, and countersigns each record.
One practical note, which is about protecting you rather than qualifying the above: the Georgia Composite Board verifies hours at the point of licensure application. Contemporaneous, countersigned, clearly dated records are what make a training log defensible years later. Missing signatures, vague dates, and unclassified time are among the most common reasons applications stall. Submit your record promptly — not in a batch at the end of the year.
Time estimates
What you completed
Download the record first, then click Email — your mail app opens pre-addressed to DrDarleen@orchardhumanservices.org and b@orchardhumanservices.org, with your details already in the message. Attach the downloaded file before sending.
Your training is not on file until the Clinical Director has received the record. Downloading it to your own device does not complete the requirement.
What clearance requires
Clearance is recorded by the Clinical Director and noted in the supervision file. No intern administers a suicide risk screen with an Orchard client before clearance.
This could also carry NBCC continuing education credit
Orchard holds ACEP No. 7260 and may issue NBCC CE for programs meeting ACEP standards — stated learning objectives, participant evaluation, attendance verification, and retained records. The learning objectives are already written and appear on every training record.
Building this out to ACEP standards would let associates and licensed staff receive CE certificates alongside their experience hours, and would make the training licensable to other agencies.
Standards that apply every time
Scope
- Screening instruments inform judgment. They do not diagnose.
- Interns do not diagnose, and do not document a diagnosis.
- All risk findings go to your supervisor the same day.
- Your supervisor holds the case. You are never the last line.
Practice
- Anchor the two-week timeframe aloud.
- Note any non-standard administration.
- Look at the pattern, not only the total.
- Re-administer to track change, not just at intake.
- When score and clinical impression diverge, say so in the note.
The instrument is not the encounter
A person disclosing suicidal thoughts on a form has done something difficult. Meet it accordingly — put the form down, make eye contact if that suits them, and respond to the person rather than to the item number.
Anchor before you ask. “Thank you for being honest with me about that — it takes something to write it down. Can you tell me more?” Then ask directly, and stay in the room while they answer.
Reference materials
A pocket reference covering all three instruments, and the documentation templates. On Orchard letterhead, Word-editable.
References
- Kroenke, K., Spitzer, R. L., & Williams, J. B. W. (2001). The PHQ-9: Validity of a brief depression severity measure. Journal of General Internal Medicine, 16(9), 606–613. https://doi.org/10.1046/j.1525-1497.2001.016009606.x
- Posner, K., Brown, G. K., Stanley, B., Brent, D. A., Yershova, K. V., Oquendo, M. A., Currier, G. W., Melvin, G. A., Greenhill, L., Shen, S., & Mann, J. J. (2011). The Columbia-Suicide Severity Rating Scale: Initial validity and internal consistency findings from three multisite studies with adolescents and adults. American Journal of Psychiatry, 168(12), 1266–1277. https://doi.org/10.1176/appi.ajp.2011.10111704
- Spitzer, R. L., Kroenke, K., Williams, J. B. W., & Löwe, B. (2006). A brief measure for assessing generalized anxiety disorder: The GAD-7. Archives of Internal Medicine, 166(10), 1092–1097. https://doi.org/10.1001/archinte.166.10.1092
- Stanley, B., & Brown, G. K. (2012). Safety planning intervention: A brief intervention to mitigate suicide risk. Cognitive and Behavioral Practice, 19(2), 256–264. https://doi.org/10.1016/j.cbpra.2011.01.001
- Columbia Lighthouse Project. (n.d.). Columbia-Suicide Severity Rating Scale training and materials. https://cssrs.columbia.edu
Dr. Darleen Claire Wodzenski, MS ESE, MA CMHC, PhD, LPC, NCC, ACS · Orchard Human Services, Inc. · NBCC ACEP No. 7260
Clinical training for interns, practicum students, staff, and associates under supervision. Screening instruments inform clinical judgment and do not establish diagnosis. All risk findings require same-day supervisor consultation. This training does not replace agency policy, supervision, or the instrument developers’ own required training.