STUDENTSAFETYPLAN SUICIDE PROTOCOL DRAFT
REQUESTFORASSISTANCE
- Oncea studenthasexpressedharmto selfand/orothersideation,the counselorwill benotifiedimmediately.
- If the counselor isnotavailable, thenursewillbe contactedto completetheStudent Safety Plan Protocol.
- The counselor/nursenotifies thePrincipal/Principal’s DesigneeIMMEDIATELY.Ifthe Principalis not available,itisthePrincipal’sDesignee’sresponsibility to notifythePrincipal.
- AllschoolcampusadministratorswillbetrainedtocompletetheStudent SafetyPlan Protocolintheeventthatthecounselor/nurseisunavailable. Districtsocialworkers/personnelwill be contactedONLYifno one isavailableattheschoolto completeanassessmentor ifadditional assistanceisneeded.
- Allemergenciesthatrequire911assistanceshouldbecalledinimmediatelytotheCentralOffice-HealthServicesDepartmentat[Insert phone number]ortheSecurityDepartmentat[Insert phone number]Anyseriousinjuriesshouldbereportedtoyourschoolnurseas soon aspossible.
PARENTALNOTIFICATION
Note: Thecounselor/nurse/principal/principal’sdesigneewillremainwiththestudentuntiltheparent/guardianarrives.
1.Thecounselor/nurse/principal/principal’sdesigneewillcontactandmeetwiththeparent/guardianimmediately.Thepurposeoftheemergencyconferenceistodiscussthestudent'simmediatepsychologicalandsafetyneeds,includingsupervision.Topics tobediscussedshouldinclude:
a.current statusof student.
b.student'sexactreferencetoharmselfand/orothers.
c.importanceofparental roleinprovidingsupervision.
d.stepstobetakentosupervisethestudent(toensuresafety):line-of-sightsupervision,removingallmeansofharm(e.g.removalofweapons,pills,knives,belts,shoestringsetc.)fromthestudent'saccess,importance of continuous observation,etc.
e.assist thestudent/family inseekingmedical/mentalhealthservicesasneeded.
2.Ifthecounselor/nurse/principal’sdesigneecannotreachaparent/guardianbyphone,theywillcalltheemergencycontactsthat wereprovidedbytheparent/guardian. Iftheparent/guardianisunabletobelocated,thecounselor/nurse/principal/principal’sdesigneewillcall[Insert phone number](non-emergencypoliceor Sheriff department)for assistancewith locatingparent/guardian.
3.Ifthestudentistakentothehospital,thecounselor/nurse/principal/principal’sdesigneewillaccompanythechild.Oncetheparent/guardianarrives,thecounselor/nurse/principal/principal’sdesigneemaychoosetoremainbut isno longerrequired.
4.Counselor/Nurse/Principal/Principal’sDesigneewillONLYprovidetheparent/guardianwithacopyoftheStudentSafetyNoticeandtheNoticeofEmergencyConferenceForm.Theparent/guardianwillbeadvisedthatitisinthebestinterestofthestudenttobeevaluated/assessedbyamedicaldoctor/mentalhealthprofessionalbeforereturning to school to ensurethat he/sheis no longer atriskofharmingselfor others.
5.Ifastudentdoesnotlivewithhis/herlegalguardian,theprimarycaregiverand/oradultinthehouseholdmustalsobecontacted,notifiedofthestudent'sstatusandaskedtoassistthestudentinseekingmedical/mentalhealthassistance.
Student Safety Plan Suicide Protocol adapted from Mobile County Public School System Student Safety Plan Protocol
6.Theparent/guardianwillbeaskedtosigntheStudentSafetyNoticeandtheNoticeofEmergencyConferenceForm.Theparent/guardianwillalsobeaskedtoindicatewhethertheywillseekmedical/mentalhealthassistancefortheirchild.Thisformacknowledgesthattheparent/guardianhasbeennotifiedofhis/herchild'sbehaviorsandtherecommendationsfortreatmentoptions.Theformwillbekeptinaconfidentialfileseparatefromthe student’scumulative folder.
7.Iftheparent/guardianagreestoseekmedical/mentalhealthassistance,thecounselor/nurse/principal/principal’sdesigneewillassistparent/guardian withmakingan appointmentBEFOREthestudentandparent/guardianleavetheschoolcampus.Inaddition,studentandparent/guardianwillbenotifiedthatthestudentmustparticipateinamandatoryreadmitconferenceuponreturntoschool.
8.Ifastudentexpressesthoughtsofharmtoselfand/orothers,andcannotbelocatedinclassoroncampus,thecounselor/nurse/principal/principal’sdesigneewillimmediatelybenotified,andwillmakeeveryefforttolocatethestudent.Theprincipal/availableadministratorandparent/guardianwill,also,benotifiedimmediately.
9.Allphonecalls/conferences/attemptstonotifyaretobedocumentedontheStudentSafetyPlanDispositionForm.
10.Whenthestudentreturnstoschool,thecounselor/nurse/principal/principal’sdesigneewillconductamandatoryreadmitconferencewiththestudentandparent/guardian.Atthattime,appropriateclearancedocumentation(i.e.,dischargeform,doctor’snote,mentalhealthclearanceform,etc.)willbecollectedfromtheparent/guardian.Acopyofthisdocumentationshouldbeattachedtotheschool’scopyoftheStudentSafetyPlanProtocolandbesenttoCentralOffice,StudentSupportServices,GuidanceDepartment,Attention:[Insert local name],inanenvelopemarked“CONFIDENTIAL”.
ASSESSMENT
1.ThestudentwillbeinformedthattheirthoughtscannotbetreatedasconfidentialANDwillbesharedwithstudent'sparent/guardianandselectedauthorities.
2.Counselor/nurse/principal/principal’sdesigneewillcompletethe StudentSafetyPlanAssessmentInterviewForm.
3.TheNoticeofEmergencyConferenceFormandtheStudentSafetyNoticewillbecompletedandreviewedwith thestudentand theparent/guardian. Providethe parent/guardianwitha copyof both of theseforms.
4.AcopyoftheStudentSafetyPlanAssessmentInterviewFormcanbesentdirectlytothementalhealthprovider,ifrequested.However,pleasedoNOTgivethisassessmentinterviewformtotheparent/guardian.
FOLLOW-UP
1.Thecounselor/nurse/principal/principal’sdesigneewillsendacopyofthecompletedpacket(includingclearancedocumentation)toCentralOffice,StudentSupportServices,GuidanceDepartment,Attention:[Insert local name]inanenvelopemarked“CONFIDENTIAL”.
2.Duringthemandatoryreadmitconferencewiththeparent/guardian,thecounselor/nurse/principal/principal’sdesigneeneedstoobtainacopyoftherelease/dischargepaperwork/medicalclearancedocumentshowingthatthestudenthasbeenassessedbya medical/mental healthprovider.
3.Ifadesignee,ratherthanthecounselor,meetswiththestudentandparent/guardianinthemandatoryreadmitconference,thecounselorwillconduct afollow-upconferencewiththe studentassoon asthecounselorreturnstocampus.
4.Thecounselorwillcontinuetomonitorthestudentonce aweekforfourweeksandasneededthroughcontactwith student/teacherand/or observation.
Student Safety Plan Suicide Protocol adapted from Mobile County Public School System Student Safety Plan Protocol
SUICIDE PREVENTION
SuicidalWarningSigns
- Gives awaypersonal items
- Is very moody
- Family problems
- Physical/sexualabuse
- Lossofenergy
- Peerrejection
- Drugabuse
- Neglectofappearance
- Suddenchange(inanything)
- Askslegalquestions aboutdeath
- Talks of life afterdeath
- Endsa relationship
- Deathof friend/familymember
MajorWarningSigns
- Previoussuicide attempt
- Current talkof suicide ormakinga plan
- Strongwish to die,preoccupation withdeath
- Recent suicideattempt byafriend/familymember
- Impulsivenessandtakingunnecessary risks
WaystoRespond:DO
- Listen (notlecture).Listeningwilldecreasetheprobability ofgoingthrough with suicide.
- Assess suicide potential.Askspecificquestions.
- Do youhave aplan?
- Are themeansavailable?
- Have youattempted suicidein thepast?How? Whathappened?
- Howdo you see yourself inthe future? (showshope)
- Be supportive.Letstudentknow you careandhelp canbe sought.
- Talkopenlyandhonestlyaboutany statementsthestudenthas made.
DON’T
- Ignoretheproblem(it won’tjust “goaway”)
- Keeptheinformationsecret. Verbal threatsandplansaresignalsfor help.
- Believethatifsuicideistalkedof,thethreatwon'tbecarriedout.Suicideisveryoftentalked aboutbeforeitiscommitted.
- Bejudgmental.
- Laughitoff.
Student Safety Plan Suicide Protocol adapted from Mobile County Public School System Student Safety Plan Protocol
STUDENTSAFETYPLANEMERGENCYGUIDANCEREFERRAL
GENERALINFORMATIONStudent Name: / Birthdate:
School Name: / Grade:
Referring Person: / Title/Position:
Referral Date: / ReferralTime:
NATUREOFREFERRAL
☐Verbalthreat of intent toharmselfand/or others
☐Written threat of intent to harmselfand/or others
☐Graphic(drawing)/Pictorial of intent to harmselfand/orothers
COMMENTS
OTHERWARNINGSIGNS(CheckALLthatAPPLY)
☐Givesawaypersonalitems / ☐Neglectofappearance
☐Isverymoody / ☐Suddenchange(inanything)
☐Family problems / ☐Askslegalquestionsaboutdeath
☐Physical/sexual abuse / ☐Poorgrades
☐Lossof energy / ☐Talksoflifeafterdeath
☐Peerrejection / ☐Endsarelationship
☐Druguse/abuse / ☐Deathoffriend/familymember
ACKNOWLEDGEMENTOFRECEIPT
Referral ReceivedBy: / DateReceived: / TimeReceived:
Student Safety Plan Suicide Protocol adapted from Mobile County Public School System Student Safety Plan Protocol
STUDENT SAFETY NOTICE
STUDENTNAMEPERSONALRESOURCES
IfIam havingthoughtsofharmingmyselfand/orothers,Iwillgetassistancefromatrustedadult(s).
Pleaseprovidenamesandphonenumbersfortwoadultsyoutrust:
NameofTrustedAdult: / PhoneNumber:
NameofTrustedAdult: / PhoneNumber:
AGENCYRESOURCES
AGENCIESTHATPROVIDEASSISTANCE:
AgencyName:AgencyTelephoneNumber:
[Insert Local Mental Health Program below] / [Insert Local Phone Number below] /
Community Resources / Dial 211 for local community resources
National Suicide Prevention Lifeline / 1-800-273-TALK (8255)
[Insert Local Hospital Emergency Room below] / [Insert Local Phone Number below] /
SIGNATURESOFAGREEMENT
IacknowledgethatIhavereceivedthenamesandphonenumbersofprofessionalorganizationsthatcanbereached24hours aday.
StudentSignature(Grades6–12) / Date: / Time:
Parent/GuardianSignature: / Date: / Time:
Counselor/Nurse/PrincipalDesigneeSignature: / Date: / Time:
DOCUMENTATIONOFREFUSALTOSIGNSAFETYPLANAGREEMENT(Ifapplicable)
☐StudentrefusedtosignStudentSafetyNotice(Grades6–12)
☐Parentrefusedtosignand/orallowstudenttosignStudentSafetyNotice
Student Safety Plan Suicide Protocol adapted from Mobile County Public School System Student Safety Plan Protocol
STUDENTSAFETYPLANDISPOSITIONFORM
GENERALINFORMATIONStudentName: / Date: / Time:
SchoolName: / ReferredBy:
Parent/GuardianName: / HomePhoneNumber: / CellPhoneNumber:
Counselor/Nurse/Principal’sDesignee:
Statethe nature ofthestudent’sthreattoharmselfand/orothers:
DISPOSITIONOFSERVICES
Checkalloftheproceduresusedinthiscrisissituation:
☐Police/Sheriffcontacted(asneeded–incaseofdireemergency)
☐Teacher/Counselor/Administratorwaswiththestudentatalltimes(i.e.line-of-sightsupervision)
☐Studentisnottobesenttotheofficeorleftalone
☐Studentwasinterviewedprivately(StudentSafetyPlanAssessmentInterviewForm)
☐StudentsignsStudentSafetyNotice(Grades6–12)
☐Principal,Counselor,andotherappropriateschool/districtpersonnelwerecontactedandconsultedasneeded
☐Attemptstocontactparent/guardianbytelephonewas(circleone)successful/unsuccessful
☐Requestmadeforparent/guardiantocometoschooltoparticipateinEmergencyConference
☐Homevisitconductedtonotifyparent/guardian
☐Contactednon-emergencylawenforcementagencyforparental/guardiannotification
☐Parent/guardianadvisedthattheirchildexhibitsatriskpersonalbehavior
☐Parent/guardiansignsandisgivenacopyoftheNoticeofEmergencyConferenceForm& StudentSafetyNotice
☐Professionaltherapyforstudentadvisedandparent/guardianassistedinmakingarrangementsforpromptassessmentofstudentpriortostudentandparent/guardianleavingcampus
☐Referralmadetooutsideagencyorhospital–Agency/hospitalnameClick here to enter text.
☐StudentSafetyPlanAssessmentInterviewForm senttooutsideagencyorhospital
☐Agencyalertedtoexpectarrivalofparent/guardianandstudent
☐Follow-upcallwasmadetoagency/hospitaltoverifyarrivalofparent/guardianandstudenttofacility
☐Follow-upcallwasmadetoparent/guardiantodeterminedispositionofservicesprovided
Dateofcall/Outcome Click here to enter text.
☐Datemandatoryre-admitconferenceheldClick here to enter text.
☐CopyofentireSTUDENTSAFETYPLANPROTOCOLPackagesenttoCentralOffice(GuidanceDepartment)
Attention:[Insert Name] Datesent: Click here to enter text.
☐OtherClick here to enter text.
DOCUMENTATION:Aneffort wasmade to contacttheparent/guardian byphoneat thefollowing times:
Date: / Time: / Results:(Pleasecheckone)
☐Noanswer / ☐Leftmessage☐ContactedParent/Guardian
☐Noanswer / ☐Leftmessage☐ContactedParent/Guardian
☐Noanswer / ☐Leftmessage☐ContactedParent/Guardian
Counselor/Nurse/Principal’sSignature /
Date
Student Safety Plan Suicide Protocol adapted from Mobile County Public School System Student Safety Plan Protocol
STUDENTSAFETYPLAN
NOTICEOF EMERGENCY CONFERENCE
I,, theparent/guardianof,attendedaconferencewithschoolpersonnelon(date) . Ihavebeennotifiedthatbasedontheavailableinformation,mychild appearstoposetheriskof harmto selfand/orothers.
IhavebeenfurtheradvisedthatIshouldseekmedical/mentalhealthconsultationimmediatelyfromcommunityagencies.Iunderstandthattheschooldistrictisnotresponsiblefortheprovisionoftheseservices,butisalertingmetothisemergencyjustastheywouldinformmeofanyotherhealthissue.Schoolpersonnelhaveclarifiedtheschooldistrict’sresponseandrole.Ihavebeentoldthattheschoolwillfollow-upwithmychildafterthemandatoryre-admit conferencetosupport his/hertransitionback tothe classroom.Ihavebeengiven an opportunitytoaskquestionsregardingmychild’sneedsandthetypesof support/resourcesavailableformychildfromcommunityagencies.
Parent/Guardian / Counselor/Nurse/Principal’sDesignee / DateParent/Guardianrefusedtosign(checkifapplicable)
DOCUMENTATIONOFPARENT/GUARDIANCONTACT:
Aneffortwasmadetocontacttheparent/emergencycontactbyphoneatthefollowingtimes:
Date: / Time: / Results:(Pleasecheckone)☐Noanswer☐Leftmessage☐ContactedParent/Guardian
☐Noanswer☐Leftmessage☐ContactedParent/Guardian
☐Noanswer☐Leftmessage☐ContactedParent/Guardian
Theemergencyconferencecouldnotbe conductedbecauseparent/guardiancouldnot bereachedORrefusedto come gethis/herstudent.Thestudent wasnotallowedtoleave orgo homeunescortedandthefollowing actionwas taken:
Student Safety Plan Suicide Protocol adapted from Mobile County Public School System Student Safety Plan Protocol
(Check theappropriateoption)
☐Conductedhomevisittonotify parent/guardian
Student Safety Plan Suicide Protocol adapted from Mobile County Public School System Student Safety Plan Protocol
☐Contactedlaw-enforcementagency
☐Contactedemergency services(e.g.mentalhealth, hospital,paramedics)
Student Safety Plan Suicide Protocol adapted from Mobile County Public School System Student Safety Plan Protocol
STUDENTSAFETYPLANASSESSMENT
InterviewForm
StudentName:FirstLast / Date:School: / Time:
Grade: / Date of Birth: / Age:
***Introduceyourself,yourrole, andreasonformeetingwiththestudent***
“I’m<NAME>andIwasaskedtotalkwithyoubecausethingsmightnotbegoingwellforyou.Iwastold
<SUMMARIZEREASONFORREFERRAL>.”
•Wouldyoutellmeinyourownwaywhatisgoingonorwhathappened?
•Doyouthinkthings will getbetterorareyouworried/afraidthingswillstaythesameorgetworse?
Whatmakesyousaythat?
•What,ifanything,
--couldmakethesituationbetter?
--wouldmakeitworse?
Student Safety Plan Suicide Protocol adapted from Mobile County Public School System Student Safety Plan Protocol