Level 1 Student Mental Health Screening Survey

Introduction: We know that stress and anxiety have increased for many students, parents and teachers during the pandemic.  And, we know that any time of transition (when things change from your “routine”) can be particularly stressful.  Increased stress does not automatically mean that thoughts of suicide or risk of suicide increase, but it is possible that one more stressor can add to the “pile” of stress that a student feels.  We want to take this opportunity to check in with you about how you are doing, and whether you are experiencing thoughts of suicide.  This survey is from your School Counseling department, and we will keep your responses confidential except if you tell us that you are in danger of hurting yourself.  In that case, a kind and caring adult will reach out to you with resources and help make a safety plan.

Q1: First Name:

Q2: Last Name:

Q3: Grade: 

Q4: Period [____] teacher:

Q5: Cell phone number:

Q7: School email address: 

Q8: I have experienced more stress or anxiety since COVID19 started. (Yes/No)

Q9: When I am stressed or anxious, this helps me: (check all that apply)

  • healthy activity (walking, biking, reading, etc)

  • talking to a trusted adult

  • talking to a friend

  • taking care of my physical body (eating good food, getting sleep, etc)

  • doing something generous for others

  • taking care of my spiritual/emotional self (prayer, meditation, mindfulness, etc)

  • hanging out with my family    

  • seeing a counselor or taking meds prescribed by my doctor

Q10: Please type the name of at least one trusted adult in your life. If you do not have one, leave it blank or type “none”.  (open)

Q11: If you were having thoughts of suicide, would you tell a friend/peer? (Yes/No)

Q12: If you were having thoughts of suicide, would you tell an adult? (Yes/No)

Q13: Have you had thoughts of suicide in the last month? 

Q14: If yes, in the past month, have you thought about how you might kill yourself? In what way?  

Q15: If yes, have you ever started to gather means for killing yourself (example: stockpiling meds)? 

Q16: Have you had thoughts of suicide ever in your lifetime? (Yes/No)

Q17: If yes, have you thought about how you might kill yourself? In what way?  

Q18: If yes, have you ever started to gather means for killing yourself (example: stockpiling meds)? 

Add to the end of the survey:  “If you need help now, call/email/reach out to _______________________(insert persons in your building that are ready to support students that day) or call/text 988 or (local crisis line).”