Suicide amongst Aboriginal and Torres Strait Islander people is a major cause of prema-ture mortality and a significant contributor to the health and life expectancy gap. This study aimed to estimate the prevalence of thoughts of self-harm or suicide in Aboriginal and Torres Strait Islander people attending an urban primary health care service and identify factors associated with these thoughts. Multilevel mixed-effects modified Poisson regression models were employed to an-alyse three years of data gathered during the annual Aboriginal and Torres Strait Islander health assessments. At their first health assessment, 11.5% (191/1664) of people reported thoughts of suicide or self-harm in the prior two weeks. Having children, participating in sport or community activities or being employed full-time decreased the risk of such thoughts. Conversely, factors re-lating to social exclusion including homelessness, drug use, unemployment and job insecurity increased the risk of thoughts of self-harm or suicide. Individual clinicians, health services, and pol-icy-makers all have a role in suicide prevention. Clinicians need appropriate training to be able to respond to people expressing these thoughts. Aboriginal and Torres Strait Islander community or-ganisations need sovereignty and self-determination over resources to provide programs that pro-mote cultural connectivity and address social exclusion, thereby saving lives.