Clinical risk framework

Universal Clinical Risk Framework + Addenda A–F

Contents

Universal Clinical Risk Framework

Purpose

This framework provides a consistent structure for identifying, assessing, and responding to clinical risk across all client presentations at Houston Heights Therapy. It applies to all clinicians regardless of experience level. When in doubt, consult with the clinical supervisor.

Core assessment domains

For any risk presentation, assess across four domains:

Risk tier definitions

Low risk
Passive ideation only, no plan, no history of attempts, intact protective factors, able to engage in safety planning.
Moderate risk
Active ideation without specific plan, some intent, history of self-harm without lethal attempts, diminished protective factors, able to engage in safety planning with support.
High risk
Active ideation with plan, stated intent, access to means, history of attempts, significant protective factor erosion, unable or unwilling to engage in safety planning.

Response by tier

Low: Complete safety plan or review existing plan. Document risk level and clinical rationale. Continue outpatient treatment. Notify supervisor if clinical picture is unclear.

Moderate: Complete or update safety plan. Increase session frequency if clinically indicated. Notify supervisor. Document means restriction counseling. Schedule follow-up contact within 24–48 hours if high concern.

High: Do not leave client alone. Contact supervisor immediately. Facilitate higher level of care — voluntary hospitalization preferred. Involuntary hold (Emergency Detention Order) if client is at imminent risk and refuses voluntary care. Document all steps taken.

Documentation requirements

All risk assessments must be documented in the session note with: risk tier assigned, clinical rationale, domains assessed, safety plan status, and supervisor notification if applicable. Use objective language. Avoid vague terms like "low risk" without supporting clinical evidence.

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Addendum A — Suicidal ideation and behavior

Assessment focus

Assess using the Columbia Suicide Severity Rating Scale (C-SSRS) framework: ideation type (passive wish to be dead, active ideation without plan, with plan, with intent). Note frequency, duration, and controllability of ideation. Assess for protective factors: reasons for living, social support, future orientation, spiritual beliefs.

Means restriction

Means restriction counseling is standard of care for any client with active suicidal ideation. Document discussion of firearms, medications, and other lethal means. Involve support persons in means restriction planning when clinically appropriate and with client consent.

Safety planning

Use the Stanley-Brown Safety Planning Intervention (SPI). The "reasons for living" component has strong evidence base. Complete in collaboration with the client — do not read from a template. Review and update at each session when ideation is active.

Low
Passive ideation, no plan, intact reasons for living. Safety plan completed or reviewed. Continue outpatient.
Moderate
Active ideation without plan or with vague plan. Safety plan updated. Means restriction discussed. Supervisor notified. Increased frequency considered.
High
Active ideation with plan and intent, access to means, or history of recent attempt. Supervisor contacted. Higher level of care facilitated.
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Addendum B — Non-suicidal self-injury (NSSI)

Assessment focus

Distinguish clearly between NSSI and suicidal behavior — NSSI does not involve intent to die. Assess: method, frequency, medical severity, function (emotion regulation, dissociation, self-punishment, communication), and precipitating factors. Assess for co-occurring suicidal ideation — NSSI is a risk factor for suicide.

Clinical approach

Avoid shaming or punitive responses to NSSI disclosure. Explore the function of the behavior in a non-judgmental way. Means restriction (e.g., removing sharp objects from immediate access) may be appropriate. Develop a NSSI safety plan distinct from the suicide safety plan if both are indicated.

Low
Infrequent, low medical severity, stable function, no co-occurring suicidal ideation. Document and monitor.
Moderate
Increasing frequency, moderate severity, or co-occurring passive suicidal ideation. Safety plan updated. Supervisor notified.
High
High medical severity, suicidal intent present, or uncontrolled escalation. Supervisor contacted. Evaluate for higher level of care.
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Addendum C — Substance use

Assessment focus

Assess type, frequency, quantity, and route of administration. Assess for tolerance, withdrawal risk, and functional impairment. Use AUDIT or DAST screening tools as appropriate. Assess for co-occurring mental health presentations — substance use and mood, anxiety, and trauma disorders frequently co-occur.

Withdrawal risk

Alcohol and benzodiazepine withdrawal can be medically life-threatening. Clients with significant alcohol or benzo dependence who intend to stop should be referred to medical detox. Do not recommend abrupt cessation without medical clearance. Document any withdrawal risk discussion in the session note.

Low
Mild use, no withdrawal risk, intact function. Psychoeducation provided. Monitor in treatment.
Moderate
Moderate use, functional impairment, or mild withdrawal risk. Discuss level of care options. Supervisor informed if clinical picture is complex.
High
Severe dependence, withdrawal risk, or acute safety concern. Refer to higher level of care or medical detox. Supervisor contacted.
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Addendum D — Eating disorders

Assessment focus

Assess for restriction, purging, binging, compensatory behaviors, and over-exercise. Assess medical stability: fainting, cardiac symptoms, electrolyte symptoms, amenorrhea, and significant weight change are indicators of medical instability. Eating disorders have the highest mortality rate of any psychiatric condition — take all presentations seriously regardless of weight or BMI.

Scope of practice

Outpatient individual therapy at HHT is appropriate for mild to moderate eating disorder presentations in medically stable clients. Moderate to severe presentations, medical instability, or treatment non-response require referral to specialized eating disorder programs. Coordinate with the client's medical provider when eating disorder is active.

Low
Mild symptoms, medically stable, motivated for treatment. Outpatient treatment appropriate. Monitor.
Moderate
Moderate symptoms, some medical concern, or treatment non-response. Supervisor consulted. Coordinate with medical. Consider higher level of care.
High
Severe symptoms or medical instability. Do not treat in outpatient without medical clearance. Refer to eating disorder specialist or higher level of care. Supervisor contacted.
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Addendum E — Abuse, neglect & intimate partner violence (IPV)

Assessment focus

Screen for IPV routinely, not only when a client discloses. Use trauma-informed, non-judgmental language. Assess for physical, sexual, emotional, financial, and digital abuse. Assess for children in the home — mandatory reporting obligations may apply if children are present in an abusive environment.

Safety assessment

Assess lethality using validated tools (Danger Assessment). Key lethality indicators: access to weapons, escalation in frequency or severity, strangulation history, threats to kill, separation as a trigger. Do not pressure clients to leave — leaving is the most dangerous time. Focus on safety planning that respects client autonomy.

Mandatory reporting

Adult IPV is generally not mandatorily reportable in Texas (adults have the right to self-determination). However, if children are present and at risk, mandatory reporting obligations apply. Consult with the supervisor when reporting is unclear. Document all discussions and decisions.

Low
Historical abuse, current safety intact, no children at risk. Safety plan in place. Continue treatment.
Moderate
Ongoing relationship, some lethality indicators, children present but not at immediate risk. Supervisor consulted. Safety planning enhanced. Reporting considered.
High
Active danger, high lethality indicators, or children at immediate risk. Supervisor contacted. Safety plan activated. Mandatory report filed if indicated. Refer to DV resources.
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Addendum F — Integrated and overlapping presentations

When presentations co-occur

Many clients present with multiple overlapping risk factors — suicidal ideation and NSSI, substance use and IPV, eating disorder symptoms and trauma history. When presentations overlap, apply the risk tier from the highest-risk individual domain. Do not average across domains.

Supervisor consultation

Integrated or complex presentations require supervisor consultation regardless of individual domain risk tier. Document that consultation occurred, the clinical reasoning discussed, and the plan agreed upon.

Documentation for complex presentations

For clients with multiple active risk factors, maintain a running risk summary in the treatment plan that is updated as the clinical picture evolves. Do not rely solely on individual session notes to capture the full picture. The treatment plan should reflect the integrated clinical formulation.

When in doubt: consult the supervisor. Document that you consulted. Document what was decided. This protects the client and you.
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