Screener Contact Feedback Form

Instructions: Please complete one form per student you meet with.

*Required

  1. Email Address*

  2. Screener Name

  3. Student Name

  4. Appointment Time (e.g. 8:30am)

  5. Based on your conversation is the student… (mark only one)

    1. Low Risk: Provide school resource sheet and remind the student of school counseling

    2. Medium Risk: Ask the student if they have support. Tell them Social Worker will follow up with them within 2 weeks

    3. High Risk: Safety plan. Refer to school staff immediately to connect with parents

  6. If Low Risk, please explain:

  7. If Medium Risk, please explain:

  8. Continue to Sections 2 thru 4 if the student is high risk

  9. Suicidal Ideation - This section deals with the student’s thoughts about suicide and thoughts of planning a suicide attempt.

    1. Please write any notes pertaining to Questions 1-5 on the screener.

  10. Intensity of Ideation - This section asks about the time the student was feeling most suicidal

    1. Intensity of ideation: comment on frequency, duration, controllability, deterrents, and reasons for ideation.

  11. Suicidal Behavior - This section covers actual attempt, interrupted attempt, aborted or self-interrupted attempt, preparatory acts or behavior

    1. Note about any attempts