NSU University School Faculty, Staff and Employee Handbook

109 ASSESSMENT OF SUICIDE RISK - FOR USE BY ADMINISTRATION OR SCHOOL PSYCHOLOGIST OR GUIDANCE COUNSELOR Student Name I.D. # Date Counselor PROBABILITY OF ATTEMPT LOW __ MEDIUM__________ HIGH_________ Instructions: Use as a checklist and average for final assessment. Each item carries the same weight. RISK __ Low ____________Medium __High _____- __ Suicide Plan A. Details Vague some specifics knows when, where, how B. Availability of means not available, will have to get available, has close by has in hand C. Time no specific time or in future within a few hours immediately D. Lethality of method pills, slash wrists drugs & alcohol, car wreck, violent action, carbon monoxide E. Chance of intervention others present most of the time others available if called upon no one nearby; isolated Previous Suicide Attempts none or one of low lethality several low or 1 medium lethality, history of repeated threats 1 high lethality or several moderate Stress no significant stress moderate reaction to loss, pressure, or change severe reaction to loss, pressure or change Symptoms A. Coping Behavior daily activities continue as some daily activities disrupted; gross disturbances in daily functioning B. Depression with little change mild, feels slightly down disturbance in eating, sleeping, school work moderate, some moodiness, overwhelmed with hopelessness, sadness, irritability, loneliness and decrease of energy sadness, feels worthless Resources help available; significant others concerned and willing to help willing to help family & friends available but unwilling to consistently help family & friends not available or are hostile, exhausted, injurious Type of Communication direct expression of feelings and suicidal intent Inter-personalized suicidal goal (“They’ll be sorry – I’ll show them”) very indirect or non-verbal expression of internalized suicidal goal (guilt, worthlessness) Life Styles stable relationships, personality, & school performance recent, acting out behavior and substance abuse; acute suicidal behavior in stable personality suicidal behavior in unstable personality, repeated difficulties with peers, family, teachers, etc. Medical Status no significant medical problems acute but short term or psychosomatic illness chronically debilitated, or acute, catastrophic illness TOTAL CHECKS LOW MEDIUM HIGH