Suicide Risk Assessment Flowchart Manteca Unified School District

Risk level 1
Identify Student in Crisis
o Suicide ideation but no previous attempts
o No plan
o Signs of depression
o Direct or indirect threats
School Based Counselor (or) o Change in Personality
o Evidence of self-harm
Valley Community Counseling
Risk level 2
o Suicidal ideation
o Plan but no means
o Destructive behaviors
Notify Administrator o Cannot commit to safety
o Previous attempts
o Mental illness
o Alcohol/drug use
o Recent suicide to friend, family or high-
profile suicide in community/news
Risk Assessment Completed by:
o Recent trauma
VCC, Admin, PSYCH, Counselor, or Nurse (2) o Change in medication

Risk Assessment Team will determine
level of Risk assessment
*If at any moment it is determined,
the student reveals, or it is found out
that they are in immediate danger
(ingested etc.) stop the assessment
and call 911 (call Health Services
50806 & District 50729 - 50813)
*DO NOT LEAVE STUDENT ALONE*
Risk level 3
o Suicidal ideation, plan and means
o Cannot commit to being safe
o Previous suicide attempts
o Previous hospitalizations for mental health
o Recent Trauma
o Signs of depression
o Alcohol/drug use
o Recent Suicide by family or friend
o Recent suicide/goodbye letter
o Diagnosed mental health illness
o Repetitive self-injury
o Access to lethal methods
o Lack of support system
o Changes in medications

311 E. North St Phone (209) 858-0782

Manteca, CA 95336 Fax (209) 858-7513
www.mantecausd.net
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 Student Suicide Risk Documentation Form

Date student was identified as possibly Name: Date of Birth:

at risk:
Name of Parent/Guardian:

Gender: Grade: Phone Number:

Identification of suicide risk level:

Who identified student as being at risk? Reason for concern:

Indicate name where appropriate
Student:
Parent:
Teacher:
Other Staff:
Student/Friend:
Other:

Risk Assessment

Assessment conducted by: Date of assessment:

Results of assessment:

Notification of Parent/Guardian

Staff who notified Parent/Guardian: Date notified:

Parent/Guardian acknowledgment form signed: _ If no, provide reason:

311 E. North St Phone (209) 858-0782

Manteca, CA 95336 Fax (209) 858-7513
www.mantecausd.net
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 Mental Health Referral

Student referred to:

Personal safety plan developed with student and parent: _ If no, provide reason:

Mental health resource list and Student/Parent handouts given to:

Student: Date:
Parent: Date:

Staff member to conduct follow-up: Date of follow-up:

Manteca Unified School District

Student Interview Questions (to determine Suicide Risk Level)

1. Circumstances preceding referral for suicide risk assessment/summary of reason for concern:
2. Stressors/precipitants from student’s perspective (i.e. What’s going on in your life right now?):
3. Current and Recent Mood
a. On a scale of 0-10 (10 being the worst and 0 the best), how have you been feeling over the past
week? Have you been feeling depressed, hopeless, helpless, or overwhelmed?
b. How would you describe how you are feeling right now?
c. Have you self-medicated (used alcohol, prescription drugs, drugs, or smoked anything as an
escape)?
4. Current ideation
a. Assess student’s current level of suicidal ideation:

Yes No Unsure
In the past few weeks, have you wished you were dead?
Have you felt that you or your family would be better off if you were dead?
Have you felt that your life is not worth living?
Have you been thinking about ending your life or killing yourself?

If Yes or unsure for any of the above:

b. How long have you been feeling this way?

c. Have you thought about ending your life today or very soon?

311 E. North St Phone (209) 858-0782

Manteca, CA 95336 Fax (209) 858-7513
www.mantecausd.net
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 5. Plan
a. Do you have a plan for how you would end your life?
Yes/detailed and thought-out
Considering means/details are vague
No/thoughts of death without consideration of how they would kill themselves
b. If yes or considering: What is your plan (including how, when, where)?
6. Means
a. Do you have access now to whatever you need to carry out your plan? If yes, where?
7. Intent
a. Do you intend to carry through with your plan to end your life soon?
Denies intent
Endorses intent
Unclear/passive
Evasive in answering question
b. Do you intend to end your life if something does or doesn’t’ happen? _ Is there anything that
would make you more likely to want to end your life?
c. Is there anything that would make you more likely to want to live?
8. History of Suicidal Ideation/Attempts
a. Have you ever thought about attempting suicide in the past?
No
Yes When?
b. Have you ever attempted suicide before?
No
Yes When?

If yes, Description of past attempt(s), including trigger for attempt, how student attempted, and what
happened:

9. Resources/Support
a. Do you have someone in your life whom you can turn to for support?
No
Yes Who?
b. If yes: have you talked to them about how you are feeling?
Yes
No Why not?

10. Student Special Programs

a. IEP Support _
b. 504 Support _
c. Counseling in school _
d. Counseling outside of school _

311 E. North St Phone (209) 858-0782

Manteca, CA 95336 Fax (209) 858-7513
www.mantecausd.net
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 Interventions

Risk Level 1:

• Student completes protective contract/student agreement and takes copy home for parent to sign and
return (if student refuse, move to level II or III)
• Contact Parent/Guardian
• Send resources home for student and Parent/Guardian
• Mental health school counselor referral (VCC)
• Notification of administration

Risk Level 2:

• Contact Parent/Guardian, hand student to Parent/Guardian if they are committed to interventions (if
Parent/Guardian is unavailable, uncooperative, proceed to risk level III and contact SRO).
• Parent/Guardian signs parent notification form and resources given
• Mental health school counselor referral (VCC)
• Notification of administration
• Schedule Parent/Guardian follow-up meeting

Risk Level 3:

• Contact SRO
• Contact Parent/Guardian
• Parent/Guardian Signs parent notification form and resources given
• Mental health school counselor referral (VCC)
• Notification of administration
• Schedule Parent/Guardian follow-up meeting

Risk level was determined to be:

Phone call log (person called relationship to student):

311 E. North St Phone (209) 858-0782

Manteca, CA 95336 Fax (209) 858-7513
www.mantecausd.net
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 Manteca Unified School District
Protective Contract/Student Agreement

I, ____________________________, Promise to not engage in any behavior that will or may cause myself
and/or others bodily injury. If I experience any of the following thoughts, feelings, or self-injurious
behaviors:

Thoughts: Feelings: Behaviors:

Or any event that causes excessive stress, I promise to contact one or all of the individuals listed on this
contract. These individuals include:

1. Name: Number: Location:

2. Name: Number: Location:
3. Name: Number: Location:
4. Name: Number: Location:

IF NONE OF THE ABOVE ADULTS ARE AVAILABLE TO CONTACT THEN I WILL CONTACT 911 AND ASK THE
DISPATCHER FOR AN OFFICER TO CONDUCT A WELFARE CHECK TO KEEP ME SAFE.

_____________________________________________________________________________________
Printed Name of Student Date

___________________________________________________________________________________
Student Signature Date

_____________________________________________________________________________________
VCC / Counselor / School Psychologist / Admin / School Nurse Date

_____________________________________________________________________________________
VCC / Counselor / School Psychologist / Admin / School Nurse Date

_____________________________________________________________________________________
Parent/Guardian Signature Date

Suicide Hotline 1-800-SUICIDE (1-800-784-2433)

Give copy to student and place a copy in mental health school counselor’s confidential file.
DO NOT PLACE IN CUM file.

311 E. North St Phone (209) 858-0782

Manteca, CA 95336 Fax (209) 858-7513
www.mantecausd.net
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 Leslie Agostini, M.S., B.S.N., R.N., Coordinator of Health Services

Parent Contact Acknowledgement Form

Student Name: ____________________________Date of Birth: _______________________

School: __________________________________________Grade: ____________________

This is to verify that I have spoken with a member of the school’s mental health staff
Staff Name: ____________________________________________Date: ________________
Concerning my child’s suicidal risk. I have been advised to seek the services of a mental health agency or
therapist ASAP immediately.

I understand that a member of the crisis response team will follow up with me, my child, and the mental health
care provider to whom my child has been seen for within two weeks.
* Before my child goes back to class myself and my child will meet with a member of the crisis team (report
to office before coming back to school).

Parent: ______________________________________________ Date: _________________

Print name/relationship

Parent Signature: ____________________________________________________________

Parent Contact Information:

Phone number(s): __________________________________________________________

Email Address: _____________________________________________________________

School Staff Member Signature: _______________________________ Date: _____________

From DiCara, C., O’Halloran, S., Williams, L. & Canly-Brooks, C. (2009). Youth Suicide Prevention, Intervention and &
Postvention guidelines (p.45). Augusta, ME: Maine Youth Suicide Prevention Program.

From http://pausd. Org/Comprehensive Suicide Prevention Toolkit

311 E. North St Phone (209) 858-0782
Manteca, CA 95336 Fax (209) 858-7513
www.mantecausd.net
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 Post Crisis Plan
Before going back to class

Date:
Student Name:
Person meeting with student:
Parent:

I, ____________________________, Promise to not engage in any behavior that will or may cause myself
and/or others bodily injury. If I experience any of the following thoughts, feelings, or self-injurious
behaviors:

Thoughts: Feelings: Behaviors:

Or any event that causes excessive stress, I promise to contact one or all of the individuals listed on this
contract. These individuals include:

1. Name: Number: Location:

2. Name: Number: Location:
3. Name: Number: Location:
4. Name: Number: Location:

IF NONE OF THE ABOVE ADULTS ARE AVAILABLE TO CONTACT THEN I WILL CONTACT 911 AND ASK THE
DISPATCHER FOR AN OFFICER TO CONDUCT A WELFARE CHECK TO KEEP ME SAFE.
Suicide Hotline 1-800-SUICIDE (1-800-784-2433)

People that I am going to check in with while I am at school and to help improve my mood:

Name: What am I going to say to that person?

Name: What am I going to say to that person?
Name: What am I going to say to that person?
Name: What am I going to say to that person?

When I get home, I am going to talk to and will seek out these people to improve my mood:

Name: What am I going to say to that person?

Name: What am I going to say to that person?

What are things that make you happy or you find helps you not think about negative thoughts?
At School:
At Home:

Student Signature: ______________________________ Parents Signature: ______________________________

Staff Name/title: ________________________________ Staff Name/title: _______________________________

311 E. North St Phone (209) 858-0782

Manteca, CA 95336 Fax (209) 858-7513
www.mantecausd.net
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