Low Risk Criteria for Self Harm or Harm to Others
Adults only

NOTE: If patient is intoxicated, perform this screen after sober

1. No suicide or homicide attempt in past year and did not attempt suicide or homicide on this visit.
2. No active suicide plan and not homicidal.
3. Patient expresses a desire to live and not hurt anyone else
4. Does NOT live alone - is NOT homeless.
5. Family member or friend staying with or available to patient.
6. No gun in home.
7. No current hallucinations or delusions and no history of schizophrenia.
8. Under 60 years old.

If attending ED physician agrees, patients who meet above criteria may be discharged home without a telepsych consult.
Fax referral form to Community Care Partners of Greater Mecklenburg (CCPGM) with patient information (sticker).
​
CCPGM will contact patient within 24 hours to reassess for danger to self or others and to
arrange further mental health or substance abuse care.

Referral Form