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

☐ 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

 

☐ 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 ________________________________________________.

 

[1] Adapted from SAVE.org