For suicidal ideation, established best practices include conducting a thorough risk assessment using a validated tool (e.g., the C-SSRS), collaboratively completing a Safety Plan with a client, and assessing and documenting risk and protective factors. For homicidal ideation or credible threats toward a third party, duty-to-warn obligations vary by state. Consulting your malpractice carrier is advisable when navigating these situations. For intimate partner violence (IPV), safety planning that accounts for the client's relationship context and lethality risk is considered a best practice. Non-suicidal self-injury (NSSI) is clinically distinct from suicidal behavior and warrants careful ongoing assessment of frequency, severity, and function. Across all areas of clinical risk, best practice includes using evidence-based interventions to directly address the underlying factors driving that risk.

→Administering and interpreting the Columbia Suicide Severity Rating Scale (C-SSRS) · Safety Plan FAQs · Clinical risk best practices library · Clinical Assessment and Management · National Domestic Violence Hotline · Questions to Assess for NSSI · Questions to Assess for Homicidal Ideation · Managing Suicide Risk in Telehealth Settings

Holding the intake appointment when elevated risk has been identified is considered a clinical best practice, as canceling may leave a client without support at a vulnerable moment. If you have not yet met with your client and risk has been endorsed on screening, you may consider reaching out proactively to acknowledge their responses and share crisis resources, and if they are unresponsive and known risk factors are present, contacting an emergency contact on file may be considered. It is worth noting that screener endorsements are not diagnostic indicators of acute or imminent risk. A useful question to hold is, what information do I have that suggests this client is in imminent danger? If serious concern for imminent safety remains and contact cannot be made, a welfare check through local emergency services or a mobile crisis response team may be appropriate. Documenting all outreach attempts and clinical reasoning throughout is considered a best practice.

When you do meet with your client, conducting a thorough risk assessment using a standard risk assessment such as the C-SSRS and, if suicide risk is identified, engaging them in safety planning, with lethal means restriction counseling is considered best practice.

→ What to do when risk is identified at intake · Clinical Assessment and Management · Preparing for and responding to clinical risk · Administering and interpreting the Columbia Suicide Severity Rating Scale (C-SSRS) · Safety Plan FAQs

A no-show from a high-risk client does not automatically mean they are in imminent danger. Consider attempting to contact the client directly. If they are unresponsive and known risk factors are present (e.g., active suicidal ideation, recent crisis, limited support), you may consider reaching out their emergency contact if one is on file. Documenting all outreach attempts and your clinical reasoning throughout is considered a best practice. If serious concern for imminent safety remains and contact cannot be made, requesting a welfare check through local emergency services and/or a mobile crisis response team may be appropriate based on your clinical judgment.

If a client endorsed risk on an intake screener (e.g., PHQ-9 item 9) and no-showed their appointment, the same outreach steps above may be considered. It is worth noting that screener endorsements are not diagnostic indicators of acute or imminent risk. A useful clinical question to consider is, what information do I have that suggests this client is in imminent danger? If nothing points to escalation, you may consider following and documenting the outreach steps noted above.

→ Preparing for and responding to clinical risk

Attempting direct contact with the client, and, if applicable, their emergency contact, before requesting a welfare check is a reasonable first step. If contact cannot be made and concern for imminent safety persists, you may consider contacting local emergency services for a welfare check. Before outreaching an emergency contact or conducting a welfare check, you may want to weigh the impact of breaching confidentiality, as well as the cultural significance that sending law enforcement to a client's home may carry for some communities. Given these considerations, emergency contacts and welfare checks are generally reserved for situations involving imminent danger. Documenting your reasoning throughout is a best practice.

→ Preparing for and responding to clinical risk

Active risk or a recent crisis does not automatically mean a client cannot continue in telehealth. The central clinical question is whether the level of risk can be safely managed in an outpatient, remote setting. Factors worth considering include the frequency and severity of crisis episodes, the client's ability to engage meaningfully in treatment, their access to support between sessions, and whether a higher level of care would better serve their needs. This determination rests with your clinical judgment. Clients often choose telehealth for a reason, and for many, it's the difference between accessing care and not. Many clients can be treated virtually. If you're unsure, it may help to ask whether it's the modality or the level of care that needs to change; a client may need a higher level of care rather than in-person treatment, and many higher levels of care now offer virtual options.

→ Managing suicide risk in telehealth settings · Determining appropriateness for telehealth

Grow's Care Coordination Support Program can assist with higher level of care referrals at the Intensive Outpatient (IOP) level. You may submit a referral through the Help Widget in the Provider Portal.

For clients experiencing a mental health emergency who may need inpatient hospitalization, Grow does not coordinate this care directly. It's the provider's responsibility to determine next steps based on clinical judgment, ethical guidelines, and state law, such as connecting the client with a local emergency department or engaging crisis resources (mobile crisis teams, 911) if they can't travel safely. Please document all actions taken, including referrals and rationale.

→ Care Coordination Support FAQs · Discharge planning in outpatient mental health care

Client refusal of a recommended higher level of care is one of the most common and challenging situations in outpatient work. Documenting the clinical recommendation and the client's refusal clearly, continuing to assess safety at each session, and revisiting the conversation as clinically indicated are all considered best practices.

Refusal is worth exploring clinically, as practical barriers (work, childcare, finances, etc.) may be behind it rather than rejection of the recommendation itself. A supportive other can sometimes help. If a HLOC is inaccessible to a client, other options to consider include coordinating care with a prescriber or therapist, group therapy, or peer/community support (e.g., NAMI, DBSA, AA, church groups).

Providers are not obligated to continue care indefinitely when the setting no longer meets a client's needs, and discharge planning may be a reasonable option.

→ Care Coordination Support FAQs · Discharge planning in outpatient mental health care

Mandated reporting obligations vary by state, population, and clinical context. Each provider is responsible for remaining informed about the laws and ethical standards that govern their licensure and practice. When the reporting threshold is unclear, you may consider consulting your local reporting agency (e.g., child or adult protective services) and/or your malpractice insurance carrier. Documenting your reasoning, including the information you have about the situation, what you considered, and what action you took or chose not to take, is a best practice regardless of the reporting outcome.

→ Clinical best practices: Mandated reporting · Adverse event reporting

Grow's Clinical Risk Program is available to help you think through clinical management strategies for situations involving client harassment, threatening behavior, or boundary strain, including considerations for managing the clinical relationship and ideas for personal safety planning. Consulting your own legal counsel and/or malpractice insurance carrier is always advisable in these situations. If a client has engaged in inappropriate or threatening behavior toward you, this can also be reported using the Support Widget in your provider portal, which will engage Grow's Escalations team for review.

→ Submit a Clinical Risk Consultation Request

Questions about crisis CPT codes (90839/90840), same-day session documentation, and related billing processes are common. For clinical context around documentation, Grow's clinical risk best practices library is a helpful starting point. For billing-specific questions, Grow's Provider Support team is best equipped to assist and can be reached via the Support Widget in your portal.

→ Billing best practices · Using CPT crisis codes: 90839 & 90840 · Contact Provider Support

Grow's coach feature includes built-in risk guardrails designed to detect safety-related content in client messages. If coach detects a safety concern, the client will be shown crisis resources, coach will be disabled, and an alert will be visible in your provider dashboard, allowing you to review the flagged concern and decide whether to re-enable coach for your client.

A coach safety alert is an opportunity to follow up with your client directly and apply your clinical judgment about next steps, which may include completing a C-SSRS, updating or initiating a Safety Plan, or considering whether the client remains appropriate for their current level of care. Coach is not a substitute for clinical assessment, and any risk identified through the platform is best addressed through your standard clinical process.

→ Coach — Grow Therapy iOS Mobile App ·Administering and interpreting the Columbia Suicide Severity Rating Scale (C-SSRS) · Safety Plan FAQs

• Administering and interpreting the Columbia Suicide Severity Rating Scale (C-SSRS)
• Care Coordination Support FAQs
• Clinical risk assessment & management
• Conducting post-psychiatric hospitalization appointments for therapists
• Conducting post-psychiatric hospitalization appointments for prescribers
• Determining appropriateness for telehealth
• Discharge planning in outpatient mental health care
• Emergency resources
• Managing suicide risk in telehealth settings
• Questions to assist with assessing for suicidal ideation
• Preparing for and responding to clinical risk
• Safety Plan FAQs
• Support with lethal means restriction counseling
• Using CPT Crisis Codes

• Clinical Risk Assessment & Management resource library
• Clinical Risk Support Program channel
• Is my client appropriate for telehealth?
• Elevated PHQ-9 with an intake scheduled

• Clinical Risk Peer Consultation Group
• Request to consult with the Clinical Risk Program