CODY PUBLIC SCHOOLS SUICIDE INTERVENTION FORM [Confidential Information] 1.
Student’s Name: _______________________________Age_________ Sex__________
2.
Date Referred:_________________________ Date of Birth:______________________
3.
School ____________________________Teacher______________________________
4.
Parent’s Names:__________________________________________________________
5.
Parent’s Address:________________________________________________________
6.
Phone: [Home]__________________________ [Work] __________________________
7.
When incident occurred:___________________________________________________
8.
Who referred:___________________________________________________________
9.
Content of referral incident: [Attach Early Alert-If applicable] _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________
10.
Self-destructive method/specifics of plan: _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________
Is implement available? [knife, gun, razor blades,etc.]
yes
no
11.
Describe student’s concept of death [finality, attractiveness]: _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________
12.
Who does the student think would be most affected by his/her death: _______________________________________________________________________
13.
What is the goal of suicide?________________________________________________ _______________________________________________________________________
14.
Category of present self-destructive behavior. _____Serious attempt
[check any that apply]:
[doing something that he/she believes will cause death, having the conscious intent to die].
_____Mild attempt[a self-destructive act which the student perceives would not be a serious threat to life].
15.
_____Suicidal threat
[saying or doing something that indicates a self-destructive desire].
_____Suicidal ideation
[having thoughts about killing oneself].
History of suicidal behavior:
Prior threat [s] _____yes _____no
_____Self
_____Significant other:
Who___________________When_________________
Describe:_____________________________________________________________________ _____________________________________________________________________________
Prior attempts [s] _____yes
_____no Who__________________When________________
Describe:_____________________________________________________________________
16.
History of counseling or mental health: [check and circle any that apply] Stresses: ____ Loss of love person by death, separation, divorce, alienation (Check and [who, when] circle any that apply) ____ Loss of peer relationships, friendships ____ Absence of warm adult parental figure ____ Family factors (unemployment, frequent moves, frequent fights, abuse, foster care, suspected drug and alcohol
abuse in the family, etc.) ____ Poor school and academic performance ____ Much pressure to achieve ____ Loss of health through sickness, surgery or accident ____ Threat of prosecution, criminal involvement, or exposure ____ Other stressors (anticipated loss, etc.) Symptoms:
____ Disturbance in sleep/nightmares ____ Disturbance in appetite ____ Weight loss/gain ____ Social withdrawal/acting out/wide mood swings/ temper tantrums ____ Evidence of marked rage or depression (fire setting, vandalism, encopresis, etc. ____ Disturbance of overall activity level (hyper/slowed down) ____ Accident proneness ____ Truancy, running away ____ Poor impulse control ____ Physical complaints
Symptoms continued:
____ Recent use of professional medical help (last three months ____ Change in personal appearance ____ Preoccupation with death ____ Evidence of final arrangements i.e. giving away of prized possessions. ____ increased trouble concentrating ____ Confused thinking ____ Tunnel vision ____ Seeing, hearing, feeling what is not there (hallucinations) ____ Extreme misinterpretations of events and others’ behavior (delusions)
Feelings:
____ Hopelessness, helplessness
____ Anxiety
____ Feels should be punished
____ Anger/rage
____ Feels a lack of alternatives
____ Sadness/Depression
____ Feels a lack of support from significant others
____ Self-blame/guilt ____ Fears loss of control
____ Inability of form relationships/connect with interviewer 17.
Medical information (student/other family members): ____ Alcohol/drug misuse (Who? Describe pattern and quantity).
____ Student or family member is suffering from a chronic, debilitating illness (mental or physical) which has involved considerable change in self-image and selfconcept. (Who? Describe)
____ Change in general physical health (who? Describe)
18.
Resources (as seen by child)
19.
Does suicidal impulse seem imminent?
Lethality: 20.
Other possible Resources
____ High
Crisis team Members:
Yes
No
____ Medium
____ Low
A.
__________________________________
B.
__________________________________
C.
__________________________________
D.
__________________________________
Plan of Action:
Person Responsible:
Date/Done:
_____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________
Check actions Taken:
Who
When
By Whom
____ School administrator notified
___________________________________________________
____ Parents notified
___________________________________________________
____ Police notified
___________________________________________________
____ Social Services notified ___________________________________________________ ____ Mental Health notified
___________________________________________________
____ Others (specify) ___________________________________________________ PARENT CONTACT SHEET (SUICIDE THREAT)
Child's Name:______________________________
Date of Contact________________
Interviewer (s) Name_________________________________________________________ Parent Contacted_____________________________________________________________ Describe reaction of parent (s) to threat:
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
Yes or No ____ parent notified as to threat ____ mental health recommended ____ parent agreed to mental health