CRISISSAFETY RESPONSE TEAM TRACKING FORM

CRISIS/SAFETY RESPONSE TEAM TRACKING FORMDATE: _____________ TIME: __________ PLACE: ___________________ NAME:_____________________________________________________________ DESCRIPTION OF INCIDENT:ACTION TAKEN:Please include in your description the names of all persons present and/or involved and a behavioral description of the incident. (i.e., who did what to whom?)SIGNATURE: ___________________(Person taking action)LAFOURCHE PARISH SCHOOL BOARDOffice Of SuperintendentP. O. Box 879Thibodaux, Louisiana 70302Date ________________NOTIFICATION OF EMERGENCY CONFERENCEI, or we, _________________________________________________, the parents of _________________________________________________, were involved in a conference with school personnel at _________________________ ______________________________. We have been advised that our child appearsto be in a state of psychological and/or physical emergency.________________________________________________________________ ___Type of EmergencyWe have been further advised that we should seek medical/psychological/psychiatric consultation immediately. We have been provided with a list of agencies and emergency numbers. We understand that the school district is not responsible for the provision of these services, but is alerting us to this emergency just as they would inform us of any health problem._____________________________ ____________________________ Parent or Legal Guardian School Personnel, Title_____________________________ ____________________________ Parent or Legal Guardian School Personnel, Title_______ Parent refused to sign.CRISIS/SAFETY RESPONSE TEAM TRACKING FOLLOW-UP FORMSTUDENT NAME:_________________________________________________ Contact OneDATE: ______________ FOLLOW-UP: ________________________________ ________________________________________________________________ SIGNATURE: _____________________ ____________________________ (Person taking action) (Principal)Contact TwoDATE: ______________ FOLLOW-UP: ________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________SIGNATURE: ________________________ ___________________________ (Person taking action) (Principal)Contact ThreeDATE: ______________ FOLLOW-UP: ________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ SIGNATURE: ___________________ ____________________________ (Person taking action) (Principal)SUICIDE ASSESSMENTDate of Interview: _____________________Team Members:________________________ and _____________________Student: ________________________ School: ____________________ What has happened to make life so difficult?Are you thinking of suicide?How long have you been thinking about suicide (FID)?Frequency:Intensity:Duration:Do you have a suicide plan?Do you know someone who has attempted or committed suicide?Tell me some reasons why you might want to die.Tell me some reasons why you might want to live.What do you think death is like?Have you attempted suicide in the past?If yes, how long ago was this previous attempt?Have you been feeling depressed?Is there anyone that might be able to stop you from completing your plan? Do you use alcohol or other drugs?Have you experienced significant losses during the past year or earlier losses you've never discussed?Have you been concerned, in any way, with your sexuality?Is there any history of mental illness in your family?On a scale of 1 to 10, with 1 being low and 10 being high, what is the number that depicts the probability that you will attempt suicide?When you think about yourself and the future, what do you visualize?Crisis Management Decisions:Notify parent(s) _______Write Suicide Contract _________Further assessment by Mental Health Clinic _______•Call to Crisis Intake Officer at 537-6823•Completion of Reciprocal Release Form (Appendix K)•Fax Copy of Release and Appendix B.1 to 537-5519Organize a protective watch and means restriction (educate family on how to) Other (describe):Signatures of team members involved in the assessment:______________________ _____________________ _______________________ Adapted from Youth At Risk, Second Edition by David Capuzzi & Douglas GrossLETHALITY ASSESSMENT CHECKLISTStudent:________________________ Date: _______________ Age: _____ Person/s Completing Form:_______________________________A. Background1. Does the child have a history of violence, criminal behavior, or severeanger problems?2. Is there a family history of criminal behavior?3. Does the child have a history of violence toward pets or animals?4. Does the child have a preoccupation with violence?5. Has the child ever brought a weapon to school?B. Environmental Stressors1. Has the child had a recent humiliating experience?2. Is the child involved in gang activity?3. Is the child teased or victimized frequently by her/his peer group?4. Has the child experienced a recent trauma in her/his life?C. Medical1. Has the child ever been hospitalized for psychiatric reasons?LETHALITY ASSESSMENT CHECKLIST (2)D. Social/Emotional1. Does the child use alcohol? Has the use increased recently?2. Does the child use illegal drugs? Has the use increased recently?3. Is the child preoccupied or dwelling on past or recent rejection, injustices,or unrealistic fears?E. Behavioral Observations1. Has the child had recent and significant mood changes?2. Is the child isolated from her/his peer group?3. Has the child made any destructive or threatening statements verbally,through writing, or through art?4. Has the child made statements that she/he may have reasons oropportunities to become violent?5. Has the child identified a target for violence (i.e. a potential victim)?LETHALITY ASSESSMENT CHECKLIST (3)E. Behavioral Observations1. Has the child intentionally frightened people?2. Has the child been stalking or following one or more people?3. Has the child become increasingly angry or violent over time?4. Has the child been recently involved in a violent episode, as either theaggressor or the victim?5. Does the child have a homicidal plan?Signatures of team members completing the form:______________________ ___________________ __________________*The above form was adapted from the Youth Violence Risk Questionnaire– Mentor Research Center, Portland, OR.CRISIS CONTRACTINGThe crisis team should have any student who appears to be in high risk based on his/her responses on the Suicide or Lethality questionnaire sign a contract assuming responsibility to ensure his/her own safety and the safety of others. The contract should be written up individually and signed by the student and crisis team members. The essential information required in all crisis contracts is provided below:The person in crisis should be required to agree:➢that they will not attempt suicide or homicide;➢that they will obtain a healthy amount of food and sleep;➢that they will remove items from their possession that could be used in a suicide attempt (guns, weapons, medications, etc…);➢that they will call a crisis counselor or a crisis center if there is atemptation to break the contract or attempt suicide;➢that they will write down the phone numbers of people to contact if the feeling of crisis escalates; and➢that they will specify ways their time will be structured (walks, talks, reading, etc…) upo n returning home.The crisis team members, the person in crisis, and available family members should sign the contract. A copy of the contract should be given to the person in crisis and the legal guardian in attendance.Sample contracts are provided with the necessary elements incorporated. The sample contracts will need to be individualized according to the needs and services available at the time of the crisis.Crisis Contract for Suicidal ThreatI,__________________________,a student at __________________________, Student Name Name of Schoolchoose to take responsibility for my welfare and agree not to harm myself or others in any way. I will make sure that I provide my body with a healthy dose of rest and food to insure my health. I also agree to have my parent/legal guardian help me to remove any items that I might think to use if I feel a suicidal temptation. I plan to spend time: _______________________________________________________ _______________________________________________________List possible activities (drawing, going for a walk, talking with a friend, etc…)to help clear my head and get my mind off the problems that have caused this crisis moment for me.In the event that I have suicidal thoughts at home, I agree to first tell my parent or legal guardian and then I will contact the Lafourche Mental Health Clinic at 537-6823 or the Office of Mental Health’s Crisis Hotline at 1-800-535-3694 (hotline used after 4:30 p.m. weekdays and any time on the weekend).In signing this contract, I agree to abide by it and I agree to check in with my school counselor tomorrow to let them know how I am doing/feeling._______________________ __________________________ Student Name Parent or Legal Guardian_______________________ __________________________ Witness WitnessCrisis Contract for Homicidal ThreatI, __________________________, a student at _________________________, Student Name Name of Schoolchoose to take responsibility for my welfare and agree not to harm myself or others in any way. I will make sure that I provide my body with a healthy dose of rest and food to insure my health. I also agree to have my parent/legal guardian help me to remove any items that I might think to use if I feel a temptation to harm. I plan to spend time: _______________________________________________________ _______________________________________________________List possible activities (drawing, going for a walk, talking with a friend, etc…)to help clear my head and get my mind off the problems that have caused this crisis moment for me.In the event that I have homicidal thoughts at home, I agree to first tell my parent or legal guardian and then I will contact the Lafourche Mental Health Clinic at 537-6823 or the Office of Mental Health’s Crisis Hotline at 1-800-535-3694 (hotline used after 4:30 p.m. weekdays and any time on the weekend).In signing this contract, I agree to abide by it and I agree to check in with my school counselor tomorrow to let them know how I am doing/feeling._______________________ __________________________ Student Name Parent or Legal Guardian_______________________ __________________________ Witness WitnessTherapeutic Resources Click on link on PAC webpageCrisis Response Documentation FormThis form should be completed in response to a crisis on a school campus or at a School related event in which multiple students, staff, or others are involved.。