Suicide Risk Assessment (School Setting)

Student Name: [Full name]

Preferred Name/Pronouns: [If offered]

DOB: [Date of birth]

Grade: [Current grade level]

Student ID: [School identifier]

Assessment Date: [Date of encounter]

Time: [Start time] – [End time] ([Duration])

Location: [Counseling office / Nurse office / Classroom / Virtual / Other]

Assessor: [Name, role, credentials]

Others Present: [None / Administrator / Nurse / Teacher / Interpreter / Caregiver / Peer / Other]

Triggering Event Date: [Same as assessment date / Specify if different]

Confidentiality Disclosure: [Statement that student was informed of confidentiality limits related to safety and duty to notify caregivers/administration/emergency services as needed]

Participation Limitations: [None / Student declined to answer specific questions / Student unable to participate due to: specify] (If limitations present, document mitigation steps taken.)

Presenting Concern

Referral Source: [Self / Peer / Teacher / Parent / Administrator / Anonymous tip / Social media / Other]

Reason for Referral Today: [Specific concern that prompted assessment, immediate context, precipitating events such as disciplinary issue, bullying, relationship conflict, grief, academic failure, identity-related stress] (Use quotation marks for direct student statements indicating self-harm or suicide.)

Immediate Safety Actions Taken: [Initiated supervision / Escorted student / Removed hazards / Secured location / Contacted crisis team / None required / Other] (Include timestamps.)

Sources of Information

• Student Interviewed: [Yes, alone / Yes, with others present: specify / No: specify reason and alternative safety steps taken]
• Collateral Contacts: [Name(s), role(s), contact method, timestamps] (Include parent/guardian, staff, peers, outside clinicians, crisis line, law enforcement as applicable.)
• Records Reviewed: [School records, prior assessments, attendance/discipline records, IEP/504, care plans] (List only if reviewed.)
• Reliability Considerations: [Student presentation: calm / dysregulated / limited engagement] [Suspected intoxication: Yes / No / Unknown] [Language barrier: Yes / No] [Interpreter used: Yes / No] [Cognitive considerations] [Other factors affecting reliability]

Behavioral Observations

(Include when direct contact occurred and risk is more than minimal. Omit for administrative follow-ups without direct student contact.)

• Appearance/Behavior: [Observed appearance, cooperation, eye contact, psychomotor activity]
• Speech: [Rate, volume, clarity]
• Mood/Affect: [Student-reported mood; observed affect range and congruence]
• Thought Process/Content: [Organization, coherence, themes of hopelessness or self-worth]
• Perceptions: [Perceptual disturbances endorsed / denied / not assessed]
• Orientation/Cognition: [Orientation, attention, memory as observed]
• Judgment/Impulse Control: [Observed judgment and impulse control]
• Substance/Medical Concerns: [Signs of intoxication or acute medical concerns: Present / Absent / Unknown]

Suicide Inquiry

(Use direct quotes for key risk statements. If a core element is not assessed or unknown, state "Unknown," "Student declined to answer," or "Unable to assess due to [reason]" and document mitigation steps.)

Current and Recent Suicidal Ideation

• Presence: [Student denied current suicidal ideation / Student endorsed suicidal ideation]
• Timeframe: [Last 48 hours / Past month / Worst-ever period]
• Frequency/Intensity/Duration: [Frequency, intensity, duration, ability to control thoughts]
• Triggers/Context: [Situational triggers, emotional or physiological cues]
• Reasons for Living/Ambivalence: [Protective beliefs, ambivalence about dying, future orientation]

Plan

(Complete if ideation is present.)

• Method Contemplated: [Specify / None identified / Unknown]
• Specificity: [Timing, location, perceived lethality, availability of method]
• Preparatory Acts: [Writing notes, giving away items, researching methods, practicing: Present / Absent / Unknown]

Intent

• Desire to Die vs. Escape Pain: [Description]
• Expectation of Acting on Plan: [Yes / No / Unsure / Not applicable]
• Perceived Lethality: [Student belief about lethality of method]
• Self-Safety: [Statements about ability or inability to keep self safe]

History of Suicidal Behavior

• Prior Attempts: [Approximate dates, methods, medical severity if known / Denied / Unknown]
• Aborted/Interrupted Attempts: [Description / Denied / Unknown]
• Recent Escalation: [Patterns observed / Denied / Unknown]

Non-Suicidal Self-Injury

• Behavior Type/Frequency: [Description / Denied]
• Last Occurrence: [Date / Unknown / Not applicable]
• Function: [Affect regulation, communication, other as stated by student]

Access to Lethal Means

• Firearms: [In home / Accessible elsewhere / No access / Unknown] [Ammunition access: Yes / No / Unknown]
• Medications: [Prescription / OTC access; unsecured quantities / Secured / Unknown]
• Other Means: [Sharps, ligatures, other means relevant to student's thoughts or plan]
• Means Restriction Counseling: [Provided / Not provided] [Recommendations given and caregiver agreements if contacted]

Risk Factors

• Historical: [Prior attempts, self-harm history, mental health diagnoses, family history if known]
• Current Clinical: [Hopelessness, agitation, insomnia, panic, psychotic symptoms, substance use, impulsivity]
• Psychosocial Stressors: [Bullying/cyberbullying, relationship conflict, grief, family conflict, housing instability, legal involvement]
• School-Specific: [Attendance issues, disciplinary actions, academic crisis, social isolation]
• Identity-Based Stressors: [Only if student-identified and relevant]

Protective Factors

• Supports/Connectedness: [Trusted adults, peers, specific supportive caregivers]
• Engagement/Activities: [Clubs, sports, community, faith, interests]
• Future Orientation/Goals: [Education, career, life goals]
• Coping Skills: [Effective strategies the student uses or is willing to try]
• Help-Seeking: [Willingness to accept help and use safety plan]
• Means Safety: [Verified lack of access / Caregiver commitments to secure means]

Notifications and Contacts

(Document all contacts with timestamps. Use interpreter as needed; do not use the student as translator.)

Caregiver Notification

• Contact Attempt: [Name, relationship] at [Time] via [Phone / In-person / Video / Other]. [Reached / Not reached]
• Content Shared: [Safety-related summary, next steps, means safety counseling]
• Interpreter: [Not needed / Used: language, interpreter name or ID]
• If Not Reached: [Attempts with times, voicemail left, escalation steps taken]
• Caregiver Safety Concern: [If applicable: student report, protective actions taken, mandatory reporting filed]

Internal School Notifications

• Staff Informed: [Crisis team lead / Administrator / Nurse / School resource officer / Case manager: names and times]
• Information Shared: [Minimal necessary for safety and supervision]

External Notifications

• Agency Contacted: [Mobile crisis / Emergency department / Law enforcement / CPS / None] [Time, reference number, handoff details, safety rationale for disclosure]

Safety Plan

(Include whenever the student is not immediately transferred to emergency care. Do not use "no-harm" or "no-suicide" contracts as substitute for safety planning.)

• Warning Signs: [Student-specific thoughts, feelings, situations, behaviors that signal crisis]
• Internal Coping Strategies: [At school: specify] [At home: specify]
• People and Places for Support: [Peers, trusted adults, safe locations]
• Who to Ask for Help: [Trusted adults at school, caregivers, community supports with contact information]
• Professional Resources: [School contact person and role; 988 Suicide & Crisis Lifeline; local crisis resources; after-hours plan]
• Means Safety Actions: [Specific steps, responsible person, timeline, verification plan]
• School-Day Safety: [Where student will go if distressed, adults to report to, supervision plan for transitions, check-in frequency and responsible staff]
• Copy Provided To: [Student / Caregiver / School designee] at [Time]

Risk Formulation

(Optional per district policy. If included, tie explicitly to documented facts.)

• Summary: [Synthesis of ideation, plan, intent, past behavior, access to means, current presentation, supervision availability, caregiver responsiveness]
• Risk Level: [Imminent / High / Moderate / Low] (Only if required by district policy; justify with documented facts.)
• Mitigation: [Supervision, means restriction, monitoring, safety plan, referrals, emergency transfer]

Disposition

• Decision: [Emergency response activated (911/EMS/law enforcement) / Parent pickup for immediate ED evaluation / Same-day urgent mental health evaluation arranged / Outpatient referral with monitoring supports / Return to class with structured monitoring]
• Rationale: [Based on ideation, plan, intent, access to means, prior behavior, presentation, supervision availability, caregiver responsiveness]
• Supervision: Student was not left alone while safety concerns existed. Handoff to [Name, role] at [Time]. Instructions provided: [Specify]
• Persistent Concerns Despite Denial: [If applicable: inconsistent account, third-party evidence, preparatory behavior, inability to ensure safety]

Follow-Up Plan

• Next School Contact: [Date, time, responsible staff member]
• Caregiver Re-Contact: [When and what will be confirmed: appointment scheduled, means secured, symptom monitoring]
• Referrals Provided: [School-based services, community mental health, crisis resources] (Document that resource information was given.)
• Short-Term Accommodations: [Reduced workload / Flexible deadlines / Safe space pass / Supervised breaks / None needed / Other]
• Re-Entry Planning: [If applicable following hospitalization or extended absence: planned participants and goals]

Assessor Signature: [Name, credentials] Date/Time of Documentation: [Date and time]