1. Purpose

This policy establishes a structured framework for identifying, assessing, and managing safety risks encountered in outpatient psychotherapy. It supports the least restrictive safe level of care while prioritizing client safety, clinical judgment, and collaborative intervention.

The policy ensures:

• Consistent risk assessment across clinicians
• Clear escalation and supervision standards
• Structured safety planning
• Appropriate use of emergency resources
• Defensible clinical documentation

This policy functions as the central framework governing all safety risk responses within the practice. Risk domains are addressed through specific addenda.

2. Scope

This policy applies to LMSW associate clinicians, fully licensed clinicians, and clinical supervisors. It governs responses to safety concerns arising during in-person sessions, telehealth sessions, and between-session communication.

3. Risk domains

Clinical risk may arise across multiple domains. This framework governs response to all safety concerns. Addenda provide domain-specific guidance for:

• Addendum A — Suicide risk
• Addendum B — Non-suicidal self-injury (NSSI)
• Addendum C — Substance use related risk
• Addendum D — Eating disorder and medical risk
• Addendum E — Abuse and interpersonal violence
• Addendum F — Integrated risk rule

When multiple domains are present, clinicians must respond according to the highest level of risk identified. If suicidal intent emerges, Addendum A governs the response.

4. Activation of risk assessment

A structured risk assessment must occur whenever a safety concern is disclosed by the client, observed by the clinician, suspected based on behavioral indicators, or communicated between sessions.

When risk concerns arise, clinicians should pause routine therapeutic processing and conduct a focused assessment.

5. Universal risk assessment domains

When risk assessment is required, clinicians should evaluate the following when clinically relevant:

• Nature of the safety concern
• Frequency, severity, and trajectory of the behavior
• Triggers and contextual factors
• Intentionality when applicable
• Access to means or opportunity
• Protective factors
• Ability to collaborate in safety planning
• Appropriateness of outpatient care

Assessment should focus on determining the level of risk and appropriate level of care.

6. Risk level framework

Low risk

Low risk may include passive or limited safety concerns, stable presentation, protective factors intact, and the client able to participate in safety planning.

Moderate risk

Moderate risk may include escalating symptoms or urges, ambivalence regarding safety, protective factors weakening, and behavioral instability emerging.

High or imminent risk

High or imminent risk may include intent to harm self or others, specific plan or preparatory behavior, inability to participate in safety planning, severe intoxication or medical instability, or immediate danger due to violence.

7. Safety planning standard

Safety planning must be collaborative and individualized. Safety plans should include:

• Warning signs indicating increased risk
• Internal coping strategies
• Supportive individuals the client can contact
• Professional resources including 988
• Steps to limit access to harmful methods when applicable
• Clear criteria for seeking higher support
• Identification of values or reasons for safety

Safety plans may be revised as clinical circumstances change.

8. Means safety documentation

When safety concerns involve potential harm to the client, clinicians must assess access to potentially lethal means when clinically relevant. Documentation should reflect:

• Whether access to harmful means was assessed
• Whether restriction or securing of means was discussed
• The client's response to the discussion

If access to lethal means cannot be restricted, clinicians must document the rationale for outpatient management or escalation.

9. Emergency contact documentation

Whenever possible, clinicians should obtain at least two emergency contacts for each client. When elevated risk is present, clinicians should confirm contact information is current, clarify whether each contact may be used during emergencies, establish the client's preferred order of contact, and document consent preferences.

When emergency contact outreach is required and the primary contact does not respond, clinicians should attempt the secondary contact immediately, document each outreach attempt, and if neither contact responds and imminent risk is present, escalate to emergency services (911) or the 988 Suicide and Crisis Lifeline without delay.

Clients may decline to provide emergency contacts. Refusal must be documented. When a client declines and risk is elevated, document the clinical rationale for continued outpatient management or initiate escalation as appropriate.

10. Support person involvement

When clinically appropriate and with client consent, clinicians should attempt to involve a trusted support person to assist with transportation to a higher level of care, supervision during transition, interim stabilization, and discharge planning support.

Support person involvement must respect confidentiality and client consent except when legal exceptions apply. When risk is moderate or higher, clinicians should make a documented attempt to identify and contact a trusted support person unless the client declines or clinical circumstances make it inappropriate.

11. Between-session risk communication

If safety concerns are communicated outside a scheduled session through messaging, email, voicemail, or other communication, clinicians should:

• Attempt same-day contact when feasible
• Conduct a brief risk assessment when appropriate
• Determine whether emergency escalation is required
• Document communication and response efforts

If the client cannot be reached and imminent risk is suspected, emergency escalation may be necessary.

12. Session format-specific risk procedures

In-person sessions

When elevated risk occurs during an in-person session:

• Do not leave the client alone unless safety requires it
• If the client must be left briefly, ensure another staff member or clinician is present or nearby
• Assess whether the physical environment presents any immediate access to harmful means
• Involve a trusted support person when clinically indicated and client consents
• Contact emergency services directly when imminent risk cannot be mitigated

If emergency services are contacted, the clinician should remain with the client until services arrive when it is safe to do so.

Telehealth sessions

At the start of each telehealth session, clinicians should confirm: client physical location, local emergency services jurisdiction, and whether the client is alone.

When elevated risk occurs during a telehealth session:

• Maintain connection with the client whenever possible
• Attempt collaborative safety planning
• Involve trusted support persons when available
• Contact local emergency services at the client's confirmed location when risk cannot be mitigated

Location verification and all emergency actions must be documented.

13. Escalation standards

Escalation is required when: risk increases, intent or timeline emerges, protective factors weaken, access to harmful means cannot be mitigated, client cannot engage in safety planning, or clinician uncertainty exists.

Escalation includes supervisor consultation and reconsideration of level of care.

14. Supervisor consultation standards

Low risk

LMSWs notify the supervisor the same day. Licensed clinicians use professional judgment regarding consultation needs and document accordingly.

Moderate risk

Supervisor consultation is required the same day for all clinicians. If the supervisor does not respond within a clinically reasonable timeframe, the clinician should document the attempt, proceed with safety planning, attempt supervisor contact again before the session ends, and escalate to the backup contact if no response is received and risk is worsening.

High or imminent risk

Supervisor contact is required during the session whenever possible. The clinician should not manage imminent risk in isolation.

Supervisor unavailability protocol

When a supervisor cannot be reached and risk is high or imminent, clinicians must follow this sequence:

1. Attempt supervisor contact by phone. Document time and outcome.
2. If no response within five minutes, contact the designated backup supervisor or clinical director.
3. If neither is reachable, proceed with emergency escalation based on clinical judgment. Contact emergency services when imminent risk cannot be mitigated.
4. Notify the supervisor as soon as possible after the event. Document the full sequence of contact attempts, clinical decisions, and rationale.

15. Documentation requirements

Risk-related documentation must include:

• Client statements
• Assessment findings
• Risk level and rationale
• Means safety discussion when applicable
• Supervisor consultation when required
• Level of care decision and rationale
• Follow-up plan

Clinical reasoning must originate from the treating clinician.

Addendum A — Suicide risk assessment and management

1. Activation

This addendum governs clinical response whenever suicidal ideation is disclosed by the client, suspected by the clinician, observed through client behavior, or communicated between sessions. Intent or a fully formed plan is not required for this addendum to activate. Non-suicidal self-injury alone does not activate this addendum unless suicidal desire, intent, or preparatory behavior is present.

2. Suicide-specific assessment

When activated, clinicians must assess: suicidal ideation, suicidal intent, suicide plan, access to lethal means, timeframe or urgency, preparatory behavior, protective factors, and willingness and ability to engage in safety planning. Structured tools may be used when clinically appropriate, but clinical judgment remains primary.

3. Means safety

When suicidal ideation is present, clinicians must assess access to potentially lethal means. Documentation should reflect whether access was assessed, whether means restriction or securing was discussed, and the client's response. If lethal means cannot be restricted, clinicians must document the rationale for outpatient management or escalation.

4. Safety planning

All clients reporting suicidal ideation must participate in collaborative safety planning, including warning signs, internal coping strategies, support people, crisis resources including 988, steps to limit access to harmful methods, clear criteria for seeking higher support, and identification of reasons for safety. Safety plans should be updated as risk changes.

5. Level of care decisions

Hospitalization is required when imminent suicide risk cannot be safely managed in outpatient care. Hospitalization is not required solely because suicidal ideation is present. Outpatient management may remain appropriate when imminent intent is absent, actionable plans are not present, means access has been mitigated when possible, the client can collaborate in safety planning, and supervisor consultation occurs when required.

6. Between-session suicide communication

If suicidal ideation is communicated outside session, clinicians should attempt same-day contact when feasible, conduct a brief risk assessment, determine whether emergency escalation is necessary, and document response attempts and disposition. If the client cannot be reached and imminent risk is suspected, emergency escalation may be necessary.

Addendum B — Non-suicidal self-injury (NSSI)

1. Activation

This addendum applies when a client intentionally injures themselves without clear suicidal intent. Examples may include cutting, burning, scratching, or hitting oneself.

2. Key clinical considerations

Assessment should include: function of the behavior (regulation, relief, punishment, grounding), frequency and trajectory, severity of injury, lethality of method, urge intensity and controllability, medical complications, and triggers and contextual factors.

3. Suicide assessment rule

Suicide assessment must occur whenever intent is unclear, lethality is escalating, behavior appears rehearsed, client expresses desire for death, or clinician uncertainty exists. If suicidal intent emerges, Addendum A governs the response.

4. Safety planning considerations

Safety planning should focus on identifying warning signs for urges, alternative coping or regulation strategies, delay-based coping techniques, support contacts, and obtaining medical care if injury worsens.

5. Escalation indicators

Supervisor consultation is required when injury severity increases, urges become uncontrollable, medical complications emerge, suicide risk becomes unclear, or outpatient safety cannot be maintained.

Addendum C — Substance use related risk

1. Activation

This addendum applies when substance use creates safety concerns that affect outpatient treatment, including active intoxication during treatment, relapse risk with safety implications, overdose risk, or substance use interacting with suicidality or instability.

2. Key clinical considerations

Assessment should include: pattern and frequency of use, recent escalation or relapse, intoxication affecting treatment, overdose risk, withdrawal risk, functional impairment, and interaction with suicidal ideation or self-harm.

3. Safety planning considerations

Safety planning may include harm reduction strategies, identifying high-risk situations, coping strategies for cravings, support contacts, and overdose response planning when relevant.

4. Level of care boundaries

Referral to specialized substance use treatment should be considered when withdrawal risk exists, overdose risk is significant, repeated unsafe intoxication occurs, or outpatient therapy alone is insufficient. Psychotherapy is not a substitute for specialized addiction treatment when severity exceeds outpatient scope.

Addendum D — Eating disorder and medical risk

1. Activation

This addendum applies when eating disorder related behaviors create potential medical risk, including restriction, purging, compensatory behaviors, significant weight change, or symptoms of malnutrition or instability.

2. Key clinical considerations

Assessment should include: frequency of restrictive or purging behaviors, signs of medical instability (dizziness, fainting), current medical monitoring, client insight into severity, and willingness to involve medical providers.

3. Safety planning considerations

Safety planning may include education regarding medical warning signs, coordination with medical providers, involvement of support persons when appropriate, and plans for urgent medical evaluation if symptoms worsen.

4. Referral and scope limits

Referral to specialized eating disorder treatment should be considered when symptoms reach moderate or severe levels, medical instability is suspected, or outpatient therapy alone cannot maintain safety. Specialized eating disorder care holds primary responsibility when medical risk is present.

Addendum E — Abuse and interpersonal violence risk

1. Activation

This addendum applies when a client reports ongoing abuse, credible safety concerns involving another person, coercive control or stalking, or risk of violence within their environment.

2. Key clinical considerations

Assessment should consider: immediate physical danger, escalation patterns of abuse, access to safe locations, availability of support networks, and barriers to leaving or obtaining safety.

3. Safety planning considerations

Safety planning may include identifying dangerous scenarios, exit strategies, emergency contacts, safe locations, resource referrals, and logistical planning for safety.

4. Clinical boundary

Clinicians support client autonomy and informed decision making. Clinicians do not direct clients to leave relationships. The clinician's role is to assess danger, support planning, provide resources, and escalate when legally required.

Addendum F — Integrated risk and overlap rule

1. Purpose

Clients may present with multiple overlapping risk domains. This addendum establishes how clinicians determine which risk procedures govern the response.

2. Highest risk rule

When multiple risk domains are present, clinicians must respond according to the highest level of risk identified.

3. Suicide supersession rule

If suicidal intent, planning, or preparatory behavior emerges at any point, Addendum A governs the response regardless of the initial presenting concern.

4. Medical priority rule

If medical instability is suspected, medical safety takes priority over routine psychotherapy procedures. Urgent medical evaluation may be necessary.

5. Uncertainty rule

If the clinician is unsure which addendum applies, treat the situation as at least moderate risk, consult a supervisor the same day, and document the reasoning and actions taken.