Counseling Safety Evaluation and Follow-Up Note

Risk Assessment and Safety Planning Note

Presenting Concerns and Risk Indicators

Pt Thandiwe Ndlovu (29 yo F, DOB: 14/05/1995, ID: 9505140284081, File: PSY-49201) presented at 14:00 on 24/10/2023 reporting passive SI ("wish I wouldn't wake up") and severe emotional distress following retrenchment 2 wks ago. Reports acute insomnia, anhedonia, and increased EtOH intake (approx. 4 units/day for the past wk). Denies active suicide plan, intent, or HI. Contextual stressors include imminent housing insecurity (unable to pay next month's rent).

History of Risk Behaviours

Hx of MDD, currently Rx sertraline (Zoloft®) 50 mg PO OD. One prior suicide attempt via paracetamol OD in 2018 following a bereavement; required 72-hr admission at Helen Joseph Hospital. Hx of emotional abuse in previous relationship (ended 2021). Denies hx of NSSI or violence toward others.

Protective Factors and Strengths

Strong attachment to 5 yo daughter (primary caregiver). Supportive maternal aunt living nearby in Soweto. Expresses moral and religious objections to suicide (active in local Zionist church). Good insight into triggers and help-seeking behaviour demonstrated by attending today's session.

Current Risk Assessment

Moderate risk for self-harm; no imminent danger to self or others. Rationale: Presence of passive SI, prior OD attempt, recent acute socioeconomic stressor, and increased EtOH use, mitigated by absence of active intent/plan, lack of lethal means, strong parenting responsibilities, and willingness to engage in safety planning.

Safety Plan Components

Collaboratively agreed actions to reduce risk:

• Aunt ( Zanele Khumalo) will hold pt's sertraline and paracetamol supply, dispensing daily doses only; pt agreed to pour out remaining EtOH at home.
• Emergency contacts: Aunt Zanele Khumalo (082 555 4192) and sister Lindiwe Ndlovu (073 555 8831).
• Pt and daughter will stay at Aunt Zanele's residence for the next 7 days to avoid isolation.
• Pt will reach out to her church women's group leader (Mrs Mokoena) for spiritual support and food parcel assistance.
• Crisis resources provided: SADAG 24-hr Suicide Crisis Helpline (0800 567 567), LifeLine Johannesburg (011 728 1347), or presentation to Chris Hani Baragwanath Academic Hospital ED if SI becomes active.
• Grounding techniques reviewed: 5-4-3-2-1 sensory exercise, paced breathing, and playing board games with daughter when feeling overwhelmed.

Referral or Escalation of Care

Telephonic contact made with Aunt Zanele Khumalo at 14:45 with pt's verbal and written consent; aunt confirmed willingness to supervise pt and secure medications. Referred to clinic social worker for urgent assistance with UIF application and local NGO housing/food relief. Acute psychiatric admission or EMS/SAPS involvement not indicated at this time.

Follow-up Plan

Telephonic check-in scheduled for 26/10/2023 at 10:00 to review safety plan adherence and SI status. Next in-person psychology session booked for 31/10/2023 at 11:00. Pt advised to return to clinic earlier or contact crisis lines immediately if symptoms worsen.