Regardless of their specialty, physicians encounter various potential clinical emergencies in their outpatients that may require referring patients for the appropriate level and urgency of care. One such situation is the outpatient who presents with suicidal or homicidal ideation. In this circumstance, the physician is faced with performing a rapid evaluation of the symptoms, determining the acuity of the situation, and safely referring the patient to an appropriate level of care. Using case vignettes, this article reviews some of the immediate critical factors to consider in evaluating and managing the outpatient who expresses thoughts of suicide or homicide.