District-Wide Safe Schools and Crisis Plan - Blytheville Public Schools

NO YES
10. Has the student or family member been threatened
with prosecution, criminal involvement, or exposure? ___ ___
11. Is there a lack of an effective support system for the
student, i.e. friends, family, community? ___ ___
12. Are there signs of interest in or pre-occupation with
death? (written notes, poems art work even as a joke) ___ ___
13. Is there a lack of interest in the future, avoidance
of/or refusal to discuss reasons for living, avoidance
of realistic future planning? ___ ___
14. Has the student completed any "final acts"? (giving away
valued possessions, donating body to science, writing wills or suicide notes ___ ___
15. Has the student expressed rescue needs or fantasies,
including "hints" that help is needed, such as "I'm a
burden to others" or "No one will miss me if I'm gone"? ___ ___
16. Does the student view death in a romanticized manner
or as reversible thus denying the finality of death? ___ ___
17. Has a family member or close friend ever threatened
or completed suicide? Who? Describe. ___ ___
18. Has the student considered suicide in the past,
or made previous threats? If yes, describe. ___ ___
19. Has the student made previous suicide attempts? If yes, describe. ___ ___
20. What feelings are presently being expressed by student? Check all that apply.
____Hopelessness/Helplessness ____Anxiety
____Need to be punished ____Anger
____Lack of alternatives ____Sadness/Depression
____Lack of support from significant others
21. Has student made a suicide plan? ___ ___
Record below.
a. Are the means necessary to carry out the
plan easily available? (pills, weapons, etc.) ___ ___
b. Is death a likely result? (lethality of the plan) ___ ___
c. If the plan is carried out, is the probability of rescue low? ____________________________
d. Who does the student think would be most affected by his/her death? ______________________
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