Suicide Risk and Safety Assessment Name: _ AEE EEEEE Do. Date: Time: Collateral Reporters Parent/Guardian Phone: e Outcomes (see safety plan for details): Risk Safety Plan Yes No {check box if present} oe ae Ne ianenane RIEK Resource Referral Yes. No Team Follow-Up Yes No (There is an expressed plan. The intended plan is lethal 2 The student has access to the intended means. If so, what are they? Notes: Intent and Lethality Student has recently expressed specific intent, such as through statements, poems, or letters. Student has planned a time and place to commit suicide. ‘Student made any preparations for death, such as suicide note, giving away possessions, etc. Student's observable behaviors and verbal behaviors are consistent. Student is looking for a “solution” to a situation and sees no other options. Notes: eooog Attempt History Student has previously attempted suicide. Q Previous attempt was via lethal means. Previous attempt had low rescue potential. (No communication, discovery unlikely or active precautions to prevent discovery.) Q After attempt, student expressed regret that it was not completed, continue to express desire to commit suicide, and/or show unwillingness to accept treatment. Notes: Secondary Risk Fact Predisposing Factors © Theres a history of family mental health diagnoses, There is a history of family suicide attempts Student has a history of alcohol or other chemical use. Notes: Suicide Risk and Safety Assessment 3/9/2010Name: __ Date: Time: Parent/Guardian: Safety Plan Resource Referral date: Risk Assessment Summary: 0.0.8, Collateral Reporters: Phone: _ Parent Contact date: Team Follow-Up date: Safety Plan Discussed with Student: date: Outcome: Contract with Student: date: Student Signature Provider SignatureHs NAME, DaTe_ Today, | have said some things about death or about hurting myself that have made others concerned about my safety. Others have told me how valuable my life is, but they want to make sure that | know how valuable my life is. | will complete this contract with a caring adult in order for us both to feel comfortable that | value my life and that | know what to do if | start feeling like | could harm myself again. THINGS I CAN DO OR TELL MYSELF TO MAKE MYSELF FEEL BETTER: clinician can assist PEOPLE WHO CARE ABOUT ME THAT | CAN CALL WHEN I FEEL OVERWHELMED: NAME, RELATIONSHIP, NUMBER, HOTLINE NUMBER/SI CAN CALL: AGENCY NUMBER HOURS OF OPERATION National Suicide Prevention 1-800-273-TALK 24 hours/7 days per week Lifeline (1-800-273-8255) (www. suicidepreventionlfeline.org) National Hopeline Network 1-800-SUICIDE 24 hours/7 days per week (www-hopeline.com) (1-800-784-2433) * You can always cal! 917 to ask for help, Telf the operator you are in suicidal danger. Developed by the University of Maryland ~ School Mental Health Program 2008Hs 2 ONLINE RESOURCES: AGENCY WEBSITE ADDRESS National Suicide Hotlines http://suicidehotlines.com/ National Suicide Prevention Resource Center http://www.spre.org/ Yellow Ribbon http://www. yellowribbon.org! Department of Health & Human Services National Strategy for Suicide Prevention http://mentathealth.samhsa.gov/sui leprevention! Department of Health & Human Services http://www.cde.govincipe/dvp/Suicide/ Center for Disease Control & Prevention US Department of Health & Human Services _http://family.samhsa.gov/get/suicidewar.aspx Substance Abuse & Mental Health Services Administration TWILL NOT HURT MYSELF. I WILL DO ONE OR MORE OF THE FOLLOWING INSTEAD OF HURTING MYSELF: 1) Lean come to ‘s office in to talk about my feelings, 2} Lean talk to a teacher, family member, or other trusted adult about my feelings (see List). 3) can do or tell myself some of the things | wrote down on the first page. 4) [can call one of the hotline numbers listed on page 1 or can call 911. 5) can ask someone to take me to the hospital. If no one is around, | can call 911. The hospital is a sate place where | can get help and can be safe from hurting myself. BY SIGNING THIS SAFETY CONTRACT IN THE PRESENCE OF A COUNSELOR, I AGREE TO TAKE, POSITIVE ACTIONS WHENEVER | FEEL, LIKE HURTING MYSELF. | WILL NOT HURT MYSELF OR TRY ‘TO KILL MYSELF. I WILL BE NEAR PEOPLE WHO CAN HELP ME OR WILL BE ABLE TO MAKE A PHONE CALL IF | NEED TO CONTACT PEOPLE WHO CAN HELP ME. ‘Student Date WITNESS/SCHOOL MENTAL HEALTH CLINICIAN Dare Developed by the University of Maryland ~ Schoo! Mental Health Program 2008