Student Support Services
Suicide Risk Assessment
3
FORT WORTH INDEPENDENT SCHOOL DISTRICT
Student Support Services
STRUCTURED INTERVIEW WORKSHEET for ASSESSING ACUTE RISK of SUICIDE
SECONDARY
Student Name ______ID# ______Grade ______
School ______Principal ______
Interviewer Signature/Title ______Date _____/_____/______
Initial Assessment Questions:
I. Did the student make a suicide attempt? Yes ____ No ____
ü If yes, call 911 if the student is in a state of injury (bleeding, ingested drugs, etc.), tell the school nurse, then inform the parent.
ü Otherwise, inform the parent that he or she should obtain emergency care for the student immediately.
ü In this situation, Risk is HIGH and the Suicide Risk Assessment does not need to be completed. Immediate action is required.
II. Did the student recently make a suicide threat? Yes ____ No ____
Student was referred by a teacher based on information he/she shared
Student was referred by another student based on information he/she shared
Student turned in writing or drawing of concern
Student self-referred and/or parent referred
If Yes, complete the Suicide Risk Assessment, and follow through with parent. Level of risk must be determined. Complete all sections of the Suicide Risk Assessment.
III. Did the student inflict superficial self-injury which does not appear to be lethal? Yes ____ No ___
IV. Did the student only have morbid ideations/thoughts? Yes ____ No ____
Ask if they were trying to kill themselves/did they think it would kill them. Yes ____ No ____
If Yes, continue assessment. If no, inform the parent. (Although there is no acute crisis the cutting/thoughts are more likely an indication that the child is depressed and may require a psychiatric evaluation and or psychological care. Complete the risk assessment if you are unsure about what happened.). Acute Risk will be designated as “minimal”.
V. Parent was notified Date ______Time ______
Name ______Phone #______
Parent’s Response______
VI. If the student drew a picture ask them about it, “Tell me about the picture you drew.” If the student made a statement, clarify exactly what they said, what they meant and why it was said.
Please answer the following questions after completing assessment and send this page to: FAX 817-814-2905 OR EMAIL
YES NO_
1) Assessed Risk Score ______ÿ Low ÿ Moderate ÿ High
2) Has this student been referred for Student Support services this year? ______
If so, reason______
3) Was a Suicide Risk Assessment previously completed? ______
If yes, assessed risk______Date ______
4) Was a Violent Behavior Risk Assessment previously completed? ______
If yes, assessed risk______Date ______
5) Has a Trauma Response Team meeting been conducted/Student Support
Plan been initiated? ______
6) Did the parent/legal guardian sign a Notification of Emergency
Conference Form? ______
7) Did the parent/legal guardian sign a Release of Information? ______
8) Did the parent/legal guardian agree to obtain treatment for the student? ______
9) Did the student sign an Agreement to Participate in Care form? ______
10) Is the student involved in their treatment? ______
11) Did the student return to school? Date ______ ______
12) Has there been follow-up with the student? Date ______ ______
13) Has there been follow-up with student’s family? Date ______ ______
14) Has there been follow-up with educational team? Date ______
Risk Categories
/Minimal Risk = 1
/Moderate Risk = 3
/High Risk = 5
1. SUICIDAL THINKING/ PLAN
Have you ever thought about harming/killing yourself?Details – Do you have a plan?
Availability of Method
Do you have access to these items?
Perceived Lethality – How accessible is the means?
Rescue Opportunity—Would you tell anyone before you did it? Where would you do it? Is there someone you want to send a message to? What do you want that message to be?
Time – Have you thought about when you might do this? / ____ No
____ Nonspecific
____ Not Available
____ Not Applicable Undecided
____ Certain/Others Present
____ No Specific Time / ____ Unsure
____ Vague Plan
____ Available with some or little effort
____ Potentially Lethal (e.g., drugs, alcohol)
____ Possibly/ Others Accessible
____ Within a Few Hours or Days / ____ Yes
____ Specific: With Intent
____ Immediately Available, No Preparation needed
____ Lethal (e.g., guns, hanging, jumping)
____ None/ Isolated
____ Immediate
2. PREDISPOSTION / HISTORY
Have you ever tried to kill yourself in the past?How often do you think about killing yourself?
Psychiatric History – Have you ever seen a Dr. or been in a hospital because of this?
Medication – Do you take any medication?
History of Abuse – Do you have any history of trauma or abuse? / ____ None reported
____ Just this once.
____ None reported
____ Compliant with Medication
____ None reported / ____ Single Attempt 6 mos. - 2 yrs.
____ At least once a week.
Present: No Intent
____ Present In treatment
____ Non-Compliant
____ Uncertain / ____ Multiple Attempts less than 6 mos.
____ Daily; Can’t stop thinking about it. Present: Intent
____ Present: includes prior hospitalization
____ None; No medical intervention
____ Present
Subtotal
Predisposition/History and Suicidal Thinking/Plan Subtotal is 11-13 with no High Risk indicators, risk may be assessed as “Minimal” and you may choose to stop assessment. If any three (3) indicators for Item #1 are “High”, student is at “High” risk, and items 3 – 7 should nevertheless be completed.
Risk Categories
/Minimal Risk = 1
/Moderate Risk = 3
/High Risk = 5
3. STRESSORS – Have you moved or had any losses recently?
/____ None Reported or > 12 months
/____ Within 6 months
/____ Within 3 months
4. SYMPTOMS
Depression – Do you have difficulty sleeping or eating, feel angry, lonely or fatigued?Anxiety – Do you feel nervous, worried, have trouble paying attention? [Note: Agitated individuals are the most likely to act] /
____ None - Mild
____ None - Mild /____ Moderate: Some chronic or acute moodiness, sadness, irritability, loneliness, fatigue
____ Moderate: Some chronic or acute tension, agitation, nervousness, worry /____ Severe Symptoms Major disturbance of appetite, sleep, school work, relationships or temperament
____ Severe Symptoms restless, agitated, worried, & difficulty staying focused
5. HOPELESSNESS – What do you plan to do tonight/tomorrow/next week/next year?
If you carried out this threat, what do you think it would be like afterwards? /____ Has future plans
___ People would miss me. /____ Vague plans
___ I would be out of pain. /____ No plans
___ No one would care.Total (page 1) / / /
6. MEDICAL STATUS – Do you feel sick a lot/Miss school a lot? /
____ None Reported
/____ Short-term or psychosomatic problems
/____ Chronic, debilitating or catastrophic illness
7. PROTECTIVE FACTORS
Social Support – Tell me about family & friendsCoping Behavior – How are you doing in school & relationships?
Active in Recommended Treatment – Have you seen a doctor/counselor & are you following recommendations? /
____ Available, Accessible
____ Daily activities continue as usual
____ Yes or NA
/____ Available, but Strained.
____ Mild disruption of daily activities: eating, sleeping, school work, socially withdrawn
____ Erratic, Inconsistent
/____ None or Not Available
____ Poor: Major disturbance of appetite, sleep, school work, interpersonal relations
____ Not Active in treatment despite previous recommendationTotal (pages 1 + 2)=
Scoring: ______
Risk assessment: Minimal/Routine = 20 - 30 Moderate/Urgent = 31 - 60 High/Emergent = 61 - 95
Ranges on scores are meant to be guidelines. They may not be an adequate assessment qualitatively of student risk. Please total indicators in the assessment tool.Categorization of Risk for Acute Status
If the student has made multiple suicide attempts and has at least one (1) other “High Risk” Indicator in terms of:
¨ Section 1. Suicidal Thinking/Plan,
¨ Section 3. Stressors,
¨ Section 4. Symptoms,
¨ Section 5. Hopelessness, or
¨ Section 6. Medical Status,
Then the Suicide Risk Assessment will be at least “Moderate”. Parent/guardian will be instructed to obtain counseling for student or possibly emergency psychiatric services.
If the student has Two or more (2+) Significant Findings of “Moderate or High Risk” Indicators Then the Suicide Risk Assessment will be “High” despite their OVERALL score. HIGH RISK WARRANTS REFERRAL TO COOK CHILDREN’S MEDICAL CENTER OR JPS HOSPITAL. (REFER TO SAFETY MANAGEMENT PROCEDURES).
Chronic Risk:
Please note that students who have a history of multiple suicide attempts are considered to be at chronic risk regardless of acute status with the likely need for ongoing care. If the student has a history of multiple suicide attempts, but is not active and consistent in treatment (as indicted in Section 7) then recommend to the parent that they consider getting consistent care.
Also consider other Chronic Risk Indicators in the student’s history that might warrant referral for therapeutic services. Such as
¨ Prior Psychiatric Hospitalization
¨ History of Abuse or Neglect
¨ Significant Changes in Environment
¨ Severe Loss
Note: Risk assessments cannot be performed with complete accuracy, and do not predict with certainty the future behavior of this student. The findings and recommendations contained in this assessment represent the best professional judgment of the examiner on this date. This assessment tool is confidential and will be maintained by examiner.