Form Imminent Risk Form Imminent Risk Form Imminent Risk Form

OMB No. 0930-xxxx

Expiration Date: xx/xx/xx

Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.  The OMB control number for this project is 0930-xxxx.  Public reporting burden for this collection of information is estimated to average 16 minutes per respondent, per year, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.  Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to SAMHSA Reports Clearance Officer, 1 Choke Cherry Road, Room 8-1099, Rockville, Maryland, 20857.

IMMINENT RISK FORM – COUNSELOR INFORMATION –

Your Name: ____________________ (will be replaced by ID#)

Your Center: ___________________ (will be replaced by ID#)

Today’s Date: __________________ (mm/dd/yyyy)

1. What is your employment status at your center? (Check all that apply.)

☐ Paid employee ☐ Volunteer ☐ Supervisor/Trainer

2. When did you begin working/volunteering as a telephone crisis counselor? ____________ (mm/yyyy)

3. How many hours per week on average do you answer crisis lines? _______________

4. On average, how many suicide calls do you handle per week? _____________

5. What is your highest level of education?

☐ Less than a Bachelor’s Degree ☐ Doctorate (Ph.D.)

☐ Bachelor’s Degree (B.A.) ☐ Other: ______________

☐ Master’s Degree (e.g., M.A., M.S., MSW)

6. Are you a licensed clinician / licensed mental health professional? ☐ Yes ☐ No

7. Have you completed training in ASIST (Applied Suicide Intervention Skills Training)? ☐ Yes ☐ No

If yes: 7a. Date(s) of ASIST training: ___________________________ (mm/yyyy)

8. Have you completed training in Safety Planning protocols (other than ASIST)? ☐ Yes ☐ No

If yes: 8a. Date(s) of Safety Planning training: __________________________ (mm/yyyy)

9. What is/are the source(s) of the Safety Planning protocols you use? (Check all that apply)

☐ Safety Planning protocols derived from ASIST

☐ Safety Planning protocols developed by Drs. Barbara Stanley and Gregory Brown for the Veterans Administration

☐ Safety Planning protocols developed at your center

☐ Not sure where our Safety Planning protocols came from

☐ Self-taught (e.g., researched Safety Planning on internet)

☐ Other: ______________________________

☐ N/A (not currently using Safety Planning protocols)

10. Are you responsible for conducting follow-up calls with suicidal callers/clients? ☐ Yes ☐ No

If yes: 10a. When did you begin conducting follow-up calls? _____________ (mm/yyyy)

10b. What types of follow-up do you conduct? (Check all that apply.)

☐ Immediate safety check (one to two calls within 48 hours of crisis call)

☐ Short term follow-up (lasting one week or less)

☐ Long-term follow-up (lasting more than one week)

IMMINENT RISK FORM – ADDITIONAL COUNSELOR TRAINING

Counselor’s Name: ____________________ (will be replaced by ID#)

Center: ______________________________ (will be replaced by ID#)

Today’s Date: _____/____/______ (mm/dd/yyyy)

Date of additional training: _____/_____/________ (mm/dd/yyyy)

Type of training: ☐ ASIST (Applied Suicide Intervention Skills Training)

☐ Other: _______________________________

IMMINENT RISK FORM (To be completed if imminent risk was present at any time during call.)

Center: __________________________ Counselor’s First Name/Initials:___________________

(to be replaced with ID#) (to be replaced with ID#)

Call Date: __ __/__ __/__ __ __ __ (mm/dd/yyyy) Line Called:  Lifeline  Center’s local line

1. Call Type:

 Imminent Risk Caller (i.e., imminent risk present at any time during call)

 Third Party Caller, calling about person at imminent risk

THESE QUESTIONS ARE FOR THIRD PARTY CALLS ONLY:

Third party caller was calling about his/her: (please check one)  Child  Sibling  Spouse/Significant other  Other family member:_________________  Friend  Patient  Professional Contact (e.g., student, co-worker, client)  Other:_________________________________	What is the source of the third party caller’s information about the person at imminent risk? (check all that apply)  Face-to-face contact  Telephone (voice)  Telephone (text)  Email  Social networking website  Second-hand report From?______________________  Other:________________________  Don’t know
Third Party Caller’s Gender:  Male  Female  Don’t know Third Party Caller’s Age:_____________  Under 18  18 or over  Don’t know

2. Gender of Person at Imminent Risk:  Male  Female  Don’t know

Age of Person at Imminent Risk: ___________  Under 18  18 or over  Don’t know

3. As far as you know, has your center handled an imminent risk call from (or about) this person before?

 Yes  No

Please describe why you (telephone counselor) felt this person was at imminent risk:

(If completing form by hand: PLEASE PRINT LEGIBLY.)

4. Suicidal Desire (please rate the extent to which the person at imminent risk expressed these feelings)

	None	A Little	Moderately	A Lot	DK
Hopelessness	0	1	2	3	DK
Helplessness	0	1	2	3	DK
Feeling trapped	0	1	2	3	DK
Feeling alone	0	1	2	3	DK
Perceived burden to others	0	1	2	3	DK
Psychological pain	0	1	2	3	DK
Reasons for dying	0	1	2	3	DK
Suicidal Ideation	0	1	2	3	DK
Persistence of suicidal thoughts  Fleeting thoughts/Once in a while  Persistent thoughts/A lot of the time Ability to control suicidal thoughts?  Yes  No  Don’t know

5. Suicidal Intent (please check all that apply for person at imminent risk)

 Expressed intent to die

 Plan to kill self

 Method chosen (please specify)  Cutting  Gun  Hanging  Pills

 Other _____________________________________

 Method available (please specify)  Immediately accessible

 Not immediately accessible

 Time chosen (please specify)  Immediately  Within few hours  Within few days

 Within week  Within month  Some future indefinite time

 Preparatory behaviors (not including an attempt)

 Attempt in progress

6. Suicidal Capability (please check all that apply for person at imminent risk)

 History suicide attempts If “yes”, #:_____	 Recent dramatic mood change
 Exposure to someone else’s completed suicide?	 Sleep problems:
Whose?___________________________	 Decreased sleep
 History of violence to others	 Increased sleep
 Aggression/Anger (recent acts and/or threats)	 Current intoxication
 Impulsive/Reckless behavior (current or past)	 History of substance abuse
 Increased anxiety	 Out of touch with reality (i.e. hearing voices)
 Increased agitation

7. Buffers (please rate buffers for person at imminent risk)

	None	A Little	Moderately	A Lot	Don’t Know
Social supports	0	1	2	3	DK
Planning for the future	0	1	2	3	DK
Engagement with you	0	1	2	3	DK
Core Values/beliefs	0	1	2	3	DK
Sense of purpose	0	1	2	3	DK
Reasons for living	0	1	2	3	DK
Ambivalence about dying	0	1	2	3	DK
Immediate support (someone with them)?  Yes  No

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QUESTIONS 8-9 – COMPLETE FOR PERSON AT IMMINENT RISK

8. Interventions for Person at Imminent Risk (check all that apply)

Person at imminent risk agreed to: (check all that apply)

 Get rid of means

 Take actions on his/her own behalf to immediately reduce imminent risk (e.g., person at imminent risk collaborated on safety plan)

 Involve a significant other or other third party to intervene to keep him/her safe

 A three-way call with a professional currently treating him/her

 Receive follow-up from your center

 Receive an evaluation in the home by a mobile crisis/outreach team

 A home visit by public safety officials (e.g., police, sheriff) for safety check

 Your securing transportation to take him/her to hospital (e.g.ER) for treatment/evaluation

 Other: ______________________________________________________

Without consent of person at imminent risk, you: (check all that apply)

 Sent mobile crisis/outreach team to evaluate him/her

 Sent public safety officials (e.g., police, sheriff) for safety check

 Secured transportation to take him/her to ER/hospital for treatment/evaluation

 Other: ______________________________________________________

9. Was imminent risk reduced enough so rescue was not needed?  Yes  No

QUESTION 10 – COMPLETE FOR THIRD PARTY CALLER

10. Interventions for Third Party Caller, Calling About a Person at Imminent Risk

(check all that apply)

 Obtained from third party the person at imminent risk’s contact information

 Facilitated a three-way call with the third party caller and person at imminent risk

 Facilitated a three-way call with third party caller and person at imminent risk’s treatment professional

 Confirmed the third party caller is willing and able to take reasonable actions to reduce risk including: (check all that third party caller is willing/able to do)

 Remove access to lethal means

 Maintain a close watch on the person at imminent risk until seen by a treatment professional

 Escort the person at imminent risk to a treatment professional or to a local urgent care facility

 Collaborate with a mobile crisis/outreach service to evaluate the person at imminent risk

 Used information obtained from third party caller to contact: (check all that apply)

 Person at imminent risk

 Another third party

 Person at imminent risk’s treatment professional

 Emergency service (e.g. police, ambulance)

 Other: ______________________________________________________

QUESTIONS 11-14 – COMPLETE FOR ALL CALLS

11. Did you consult with your supervisor about this case?  Yes  No

12. Barriers to getting needed help for person at imminent risk: (please check all that apply)

 Difficult to establish rapport with person at imminent risk

 Difficult to establish rapport with third party caller

 Difficult to obtain person at imminent risk’s collaboration on actions to be taken

 Difficult to obtain third party caller’s collaboration on actions to be taken

 Third party caller unwilling or unable to help with intervention

 Third party caller wished or needed to remain anonymous

 No caller ID

 Caller using cell phone, no way to determine location

 Mobile crisis/police sent, but unable to make contact with person at imminent risk

 Other barriers encountered; Describe:___________________________________________

 N/A, no barriers encountered

13. Steps taken to confirm emergency contact was made with person at imminent risk: (check all that apply)

 Stayed on line with person at imminent risk while waiting for emergency services to arrive

 Contacted local public safety answering point (e.g., 911 call center) to determine pick-up/

transport status

 Contacted ER or mobile crisis/outreach staff

 Contacted person at imminent risk directly to affirm s/he made contact with emergency service provider

 Contacted third party who took responsibility for person at imminent risk

 Contacted professional responsible for care/treatment of person at imminent risk

 Other: ______________________________________________________

 N/A, emergency contact not initiated

14. Steps taken when emergency contact was NOT made with person at imminent risk:

 Followed up with person at imminent risk to assess his/her current risk status and continuing need for service

linkage

 Contacted third party who took responsibility to conduct safety check

 Contacted person at imminent risk’s treatment professional or case worker to conduct evaluation, safety check

 Provided the person at imminent risk’s contact info to mobile crisis/outreach team for follow-up check

 Requested first responders (i.e. police) to conduct ongoing safety checks until safety confirmed

 Other: ______________________________________________________

 N/A

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