Suicide Screening Tool for School Counselors

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1 Suicide Screening Tool for School Counselors I. Risk Factors Check all that apply History of prior suicide attempts Self-injurious behaviors (past or present) Feelings of hopelessness Impulsivity Anxiety Depression Drug or alcohol abuse Insomnia Family history of suicide or suicide attempts Mental illness/psychiatric disorder Loss of a relationship, finances, or health (real or anticipated) Ongoing medical illness Family conflict History of physical or sexual abuse Social isolation Work or home-related stress Discharge from a psychiatric hospital Mental Health Provider or treatment change Access to firearms or lethal means Other risk factors: Other risk factors: Other risk factors: II. Protective Factors Complete each area. Ability to cope with stress Religious/Community Connection or Involvement

2 Ability to deal with frustration and tolerance Responsibility to others (children, family, friends, pets, etc) Positive relationships Positive therapeutic relationships Support system (family, friends, extended family, church, community resources, etc) III. Questions 1. Do you have a plan? Yes or No, if yes or no, move to the next question. Describe your plan. (if applicable) 2. What do you have access to in order to carry out your plan? 3. How long have you had suicidal thoughts? 4. What triggered those thoughts?

3 5. What has happened or changed in your life that has impacted you? 6. What type of changes has occurred in your life in the past 3 months, 6 or year? 7. Have there been any deaths in the family or have you any recent losses? 8. Have you had a family member/friend/coworker commit suicide? 9. Have you ever been treated for depression or anxiety? 10. Do you currently use drugs or have you used drugs in the past or do you have a history of substance abuse? 11. Do you or a family member suffered from any type of mental health disorder? Schizophrenia, Bipolar 12. Have you ever had a family member or friend commit suicide?

4 13. Do you have a history of attempted suicides? 14. Have you had any past or current fights with anyone? 15. What is your relationship like with your family/friends? 16. When was the last time you have seen your primary care physician? 17. Why do you want to commit suicide? Or why do you want to harm yourself? 18. Have you ever attempted before? If so, when? 19. Describe what the world would be like without you. 20. Identify at least 3-5 people they are close to that they can confide in or someone they trust. 21. Have they ever been in any type of in-patient or out-patient treatment?

5 22. Is there a family history of mental health history or drug abuse? 23. Describe your relationship with your parent, siblings, family, etc. 24. Have you ever been abused sexually, physically, emotionally? 25.Who are the most important people in your life? IV. Risk Level Severe Suicidal thoughts, specific plan that is highly lethal, and states he/she will commit suicide. High Suicidal thoughts, specific plan that is highly lethal, and states he/she will not commit suicide. Psychiatric diagnoses with severe symptoms, no protective factors, suicide attempt, and persistent ideation with strong intent or suicide rehearsal. States he/she may or may not commit suicide. Moderate Suicidal thoughts with a plan, but no intent or behavior, risk factors with few protective factors. States he/she will not commit suicide. Low Suicidal thoughts, but no plan, intent, or behavior. Modifiable risk factors (treated or controlled), strong protective factors. States he/she will not commit suicide.

6 V. Interventions Check all that apply Speak with parents/legal guardian: Date: Meet with parents/legal guardian: Date: Contact Principal/Assistant Principal: Date: Contact District Director: Date: Contact Lead Counselor (if applicable): Date Contact District/Campus Social Worker or Nurse (if applicable): Date: Provide a list of referrals to the parents/legal guardian: Date: Inpatient/Outpatient Referral Create a Crisis Plan/Safety Plan Stress Management Strategies Emergency/Crisis Numbers Hospitalization Relaxation Techniques (Deep breathing, imagery, muscle relaxation) ASK App Counseling/Psychotherapy Psychiatrists/Psychologist Referral or Follow-up Full Mental Health Evaluation Referral TALK (8255), SUICIDE Coping Skills Journaling Encourage and discuss positive lifestyle changes Encourage and discuss Exercising Encourage and discuss getting enough sleep and sunlight Remove potential means to commit suicide (pills, firearms, knives, razors, etc.) Doctor Prescribed Medication Identify triggers and create plan to address

7 Child/Adolescents Intent or Thoughts to Harm Self and/or Others Child/Adolescent s Name: Date: I,, have been informed that my son/daughter has expressed a desire to harm himself or herself, has harmed himself or herself, has thought about hurting himself or herself, is thinking about hurting someone, or has thought about hurting someone. I understand that my child may or may not need adult supervision and monitoring at home, support for their mental health, or a plan for short term and long term intervention. My child has specifically expressed or reported verbally or in writing: Suicide Ideation (verbally or written) Substance Abuse (excessive, increased) Purposelessness (no reason for living) Anxiety (agitation, insomnia, etc.) Trapped (feeling there is no way out) Experienced Self-Injury/Self-harm Has Thought About Hurting Him/Herself Has Thought About Hurting Someone Feelings of Hopelessness Withdrawing (from friends, family, society Anger (uncontrolled, rage, seeking revenge) Recklessness (risky acts/behaviors) Mood changes (dramatic) Thinking About Running Away Is thinking About Hurting Him/Herself Is Thinking About Hurting Someone Below is a list of agencies that can be contacted at any time to provide crisis support for me and/or my child. (List the names and numbers of the agencies below) Below are hospitals that can provide emergency assistance, should I need medical attention, full mental health assessment or psychological evaluation. I understand the severity of this situation and will seek additional/appropriate help for my child if needed or recommended by the therapist. I understand the severity of this situation and will not seek additional/appropriate help for my child if needed or recommended by the therapist. Parent/Guardian Signature Date Counselor Signature Date

8 I ve called the student to my office. Due Diligence Checklist I ve completed the screening process I have completed the checklists I ve informed the principal/assistant principal. I ve contacted the parents/legal guardian. The parent is meeting with me today. I have read and explained the Parent Communication Notice to the parent/s I did not leave the student alone. Disclaimer: The information provided is to be used as a resource, in addition to the policies and procedures y our district has in place. You should not replace or substitute y our district policies and procedures with the information provided, and the information should be used as a guide to help with students emotional and mental health and educational planning only. I do not guarantee the success of any services or strategies provided. Schools, Districts, School Counselors, Parents and students etc., may choose to use the information to enhance their understanding, knowledge, and skills in the area of y outh suicide prevention or they may choose not to. About: Dr. LaWanda N. Evans is a former school counselor, and has worked with students from grades Pre-K 12. Her first real life encounter with suicide was when a former student committed suicide y ears ago. Dr. Evans is a Licensed Professional Counselor, Relationship & Life Strategist, Speaker, and owner of LNE Unlimited - Counseling and Emotional Wellness. For more information, please visit Copy right 2015 LaWanda N. Evans. All Rights Reserved.

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