Conducting a Virtual Suicide Assessment Checklist
This checklist complements the guidance offered in Comprehensive School Suicide Prevention in a Time of Distance Learning, is supported by the checklist titled Preparing for School Suicide Intervention in a Time of Distance Learning: A Prevention Checklist and is designed to stimulate thinking about conducting school suicide intervention via telehealth. It should not supplant, nor is it a substitute for, approved school district protocols.
☐ 1. Determine location and contact information for primary caregivers.
☐ Caregiver’s current physical location _________________________________________________________.
☐ Caregiver’s cell phone number _______________, alternate phone number ______________, email address __________________________________ other communication options _____________________________
☐ 2. Contact primary caregiver and obtain informed consent.
☐ If indicated, parent communication with emergency response services (911) facilitated.
☐ Permission to conduct a risk assessment obtained.
☐ Permission to conduct a risk assessment NOT given (Actions taken, e.g., call protective services, ask for wellness check) _________________________________________________________________________.
☐ Intervention procedures when primary caregivers not available to provide consent _____________________.
☐ Reason for referral shared.
☐ Emergency contact information verified/obtained.
☐ Immediate recommendations for student care and supervision offered.
☐ 3. Document the reason for referral for a suicide intervention.
Risk Factors[1]
☐ Mental illness ☐ Substance use disorder ☐ Hopelessness ☐ Impulsive and/or aggressive tendencies ☐ Trauma or abuse history ☐ Major physical or chronic illness ☐ Previous suicide attempt ☐ Family history of suicide ☐ Recent loss of relationship ☐ Access to lethal means |
☐ Local suicide cluster ☐ Lack of social support and sense of isolation ☐ Asking for help is associated with stigma ☐ Lack of healthcare ☐ Exposure to suicide death ☐ Nonsuicidal self-injury ☐ Cultural/religious belief that suicide is an acceptable solution to coping challenges Other __________________________________________ |
Warning Signs1
☐ Talks about wanting to die or kill self ☐ Looks for ways to kill self ☐ Reports feeling hopeless/having no purpose ☐ Reports feeling trapped/in unbearable pain ☐ Talks about being a burden ☐ Increasing use of alcohol or drugs |
☐ Acts anxious, agitated, or reckless ☐ Sleeps too little/too much ☐ Withdraws or reports feeling isolated ☐ Shows rage or talks about seeking revenge ☐ Displays extreme mood swings Other ___________________________________ |
☐ Call 911 if there is a direct and imminent suicide threat.
☐ 4. Determine location and contact information for student at risk.
☐ Student’s exact location: street address, ________________________________, room currently in ___________
☐ Student’s cell phone number ________________, alternate phone _____________________, email address _______________________________, other communication channels _____________________________.
☐ Reason for referral clarified with student ______________________________________________________.
☐ Assent to conduct a risk assessment obtained.
☐ Action taken if student does not provide assent (consider requesting a wellness check) _________________.
☐ 5. Student suicide risk assessment interview.
☐ Call 911 if there is a direct and imminent suicide threat.
☐ Call 911 if the student terminates the assessment without reason or warning.
Suicide Thoughts
Are you thinking about suicide? _________________________________________________________________
How often do you think about suicide? ____________________________________________________________
Have you been researching suicide online? ________________________________________________________
Have you shared your thoughts about suicide with anyone? _____________________________________________
Who can you talk to that can help you cope with suicidal thinking? ________________________________________
Suicide Plan
Do you have a suicide plan? ___________________________________________________________________
How would kill yourself? ______________________________________________________________________
Do you have the means to carry out your plan? _____________________________________________________
When will you carry out your plan? _______________________________________________________________
Prior Suicide Thoughts and Behaviors
Have you had thoughts of suicide in the past? ______________________________________________________
How long ago? _______________________________________________________________________________
Have you ever tried to kill or hurt yourself in the past? __________________________If yes, when? ______________
Was there anyone that helped you cope with your prior suicidal thinking? ___________________________________
Suicide Risk Assessment Data
Data provided by district approved screening tools (e.g., CSSRS, or Suicide Safe Mobile App) ______________________
☐ 6. Primary caregiver interview.
Has your child displayed abrupt behavior changes? __________________________________________________
What is your child’s current support system? _______________________________________________________
Is there a history of mental illness? ______________________________________________________________
Is there a history of recent losses, trauma, or bullying? ________________________________________________
☐ 7. Determine risk level, select interventions, and develop student safety plan.
☐ Student at low risk (current thoughts of suicide, but no suicide plan, acknowledges helping resources)
Specify plan: _________________________________________________________________________
☐ Student at moderate risk (prior attempt, thoughts of and plan for behavior or no resources, but no time frame for behavior)
Specify plan: _________________________________________________________________________
☐ Student at high risk (thoughts of suicide, plan for behavior, time frame for behavior specified, and no helping resources)
Specify plan: _________________________________________________________________________
☐ Provided 24/7 resource numbers ☐ Connected with school/community resources ☐ 911, wellness check ☐ Mobilized prosocial support system |
☐ Identified caring adults ☐ Promoted communication and coping ☐ Provided treatment referral ☐ Protective services referral
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☐ 8. Primary caregiver action plan.
☐ Caregiver protective actions
Specify plan including specific referrals made:__________________________________________________
☐ Increased supervision ☐ Constant student supervision (including bathroom) ☐ Means restriction ☐ Provided 24/7 resource numbers ☐ Immediate treatment referral |
☐ Mobilized prosocial support system ☐ Connected with school/community resources ☐ Transported to services ☐ protective services referral
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☐ 9. Collaboration.
Share intervention actions with identified school and community crisis intervention resources. _____________________
☐ 10. Re-entry planning.
☐ Consent to obtain/exchange confidential information with treatment providers obtained.
☐ Communicate with community-based therapists/social workers/case managers.
☐ Modify re-entry planning to address remote learning re-entry and virtual connection with teachers.
☐ Provide teachers with warning signs and actions to take if warning signs are seen.
☐ Develop plan to monitor the student’s level of ideation and intent ______________________________________.
☐ Document all re-entry actions including re-entry meetings ________________________________________________.