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Suicide Screening Risk Form Erbacher

This document is a youth suicide risk screening form that asks students questions about suicidal thoughts and behaviors over the past 24 hours, week and month. If a student answers affirmatively to recent thoughts or behaviors, or reports a past suicide attempt, a full suicide risk assessment must be conducted by school mental health staff or an outside referral to evaluate safety. Contact with parents and any referrals made are also documented.

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157 views

Suicide Screening Risk Form Erbacher

This document is a youth suicide risk screening form that asks students questions about suicidal thoughts and behaviors over the past 24 hours, week and month. If a student answers affirmatively to recent thoughts or behaviors, or reports a past suicide attempt, a full suicide risk assessment must be conducted by school mental health staff or an outside referral to evaluate safety. Contact with parents and any referrals made are also documented.

Uploaded by

Sarah
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Youth

 Suicide  Risk  Screening  Form  


 
Student  name     Date  of  screen    
 
Past  24   Past   Past  
  hours   week   Month  
 
1. Have  you  wished  you  were  dead?     q   q   q  
 
2. Have  you  felt  that  you,  your  friends,  or  your  family  would  be  better  
off  if  you  were  dead?   q   q   q  
 
3. Have  you  had  thoughts  about  killing  yourself?   q   q   q  
 
4. Have  you  tried  to  kill  yourself?                                                                                          q  No      q  Yes       q   q   q  
a. If  yes,  how?  
 

b. If  yes,  when  and  where?  


 
c. Did  you  stop  yourself,  or  did  someone  stop  you?  
 
d. How  do  you  feel  now  that  they  stopped  you?  
 
 
5. Do  you  plan  to  kill  yourself?          q  No        q  Yes                  
a. If  yes,  how,  when,  and  where?  
 
 
 
If  student  checks  “past  24  hours”  or  “past  week”  to  any  question,  reports  a  suicide  attempt  at  any  time,  
or  checks  “yes”  to  question  5,  a  full  suicide  risk  assessment  must  be  conducted  for  safety.  This  may  be  
done  by  school-­‐based  mental  health  staff  or  by  referral  based  on  school  district  policy.    
 
Parents  contacted?   q   Yes   q   No  
Full  assessment  completed  by  school  staff?   q   Yes   q   No  
Outside  referral  for  assessment  made?   q   Yes   q   No  
Referred  to:  ______________________________________      Phone:    _______________________________  
                                 Email:    _______________________________  
         
Screener  name  and  credentials     Date  
 
Adapted  from  the  Ask  Suicide-­‐Screening  Questions  form  (ASQ;  Horowitz,  2012),  
the  Columbia  Suicide  Severity  Rating  Scale  (C-­‐SSRS;  Posner,  2009)  and  the  
Suicide  Ideation  Questionnaire-­‐JR  (SIQ-­‐JR;  Reynolds,  1997).      

©  Terri  A.  Erbacher,  Jonathan  B.  Singer  &  Scott  Poland.  Suicide  in  Schools:  A  Practitioner's  Guide  to  Multi-­‐level  Prevention,  
Assessment,  Intervention,  and  Postvention.  Routledge,  2015.  Permission  to  reproduce  is  granted  to  purchasers  of  this  text.  

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