Form Caller Follow-up I Caller Follow-up I Caller Follow-up Interview

OMB No. 0930-0274
Expiration Date: XX/XX/2016
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 0930-0274. Public reporting burden
for this collection of information is estimated to average 40 minutes per client 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 2-1057, Rockville, Maryland, 20857.

MI/SP Caller Follow-up Interview
Participant ID#: ______________
Date of Original Call to Crisis Center: ___________________________________________________
Center Code #: ______________________________
Caller’s original Call was to which number?  Lifeline
 Center’s other lines
 Don’t know
Date of Most Recent Known Follow-up Call from Center: ___________________________________
Date of Research Follow-Up Interview: __________________________________________________
Follow Up Interviewer's Name: _________________________________________________________

During this follow-up call, I'll be asking you some questions to find out how you were doing when
you called the crisis hotline on (date called), and how you're doing now. But, before I do that, I'd
like to ask you a few questions about your background, and a couple of questions that have to do
with the hotline service itself.
1. Age?__________

2. Gender:
 Male
 Female

3. Ethnicity:
 Hispanic or Latino
 Not Hispanic or Latino

5. Your highest level of education:
 Less than High School
 High School Graduate or GED
 Some College or Technical
School
 College Graduate
 Graduate School
(e.g., M.S., Ph.D., M.D.,
D.D.S.)

7. Your father's highest level of
education:
 Less than High School
 High School Graduate or GED

4. How would you describe your race? (endorse
all that apply)







American Indian/Alaska Native
Asian
Native Hawaiian or Other Pacific Islander
Black or African American
White
Other or Don't know

6. Currently attending school?
 Yes
 No
If “Yes,”
6a.

What type of school? ___________

6b.

Attending?
 Full Time
 Part Time

8. Your mother's highest level of education:
 Less than High School
 High School Graduate or GED
 Some College or Technical School
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 Some College or Technical
School
 College Graduate
 Graduate School (e.g., M.S.,
Ph.D., M.D., D.D.S.)
 Don’t know

 College Graduate
 Graduate School (e.g., M.S., Ph.D.,
M.D., D.D.S.)
 Don’t know

9. Have you ever served in the military?
 Yes

 No

 Prefer not to answer

If “Yes”:
Are you currently serving in the military?

 Yes

 No

 Prefer not to answer

If “Yes”: Are you on active duty?

 Yes

 No

 Prefer not to answer

Are you currently a member of the Reserves or National Guard?
 Yes

 No

 Prefer not to answer

Have you ever served in a combat zone or on a peace-keeping mission?
 Yes

 No

 Prefer not to answer

If “Yes”:
Where? (Do not read list. Code caller’s response below by checking all that apply)
 Afghanistan
 Kosovo
 Bosnia
 Saudi Arabia (Desert Storm/Desert Shield)
 Iraq
 Vietnam
 Korea
 Other_________ (e.g. Qatar, Kuwait, Panama)
10. Employment Status:








Employed Full Time
Employed Part Time
Homemaker & Employed
Homemaker & Not Employed
Retired
Unemployed
On Disability

12. Are you currently living with
someone in a marriage-like
relationship?
 Yes
 No

11. Are you currently (read choices)?
 Married
 Separated
 Divorced
 Widowed
 Never married

13. Household composition? (check all that apply)







Spouse/Partner
Children (If “Yes,” Number:_____)
Parent(s)
Other family Member(s)
Non-family Member(s)
Live alone

Page 2

14. How long have you lived at your
current address?
(circle unit of time)
___( # ) _____

days

months

years

15. Since the age of 18, have you ever been
homeless?  Yes  No
If “Yes,”, How long homeless since age 18?
(circle unit of time)
___( # ) _____

days

months

years

16. Do you mind telling me how you found out about the crisis hotline?
(Code caller’s responses, DO NOT read list)













Agency
Billboards
Brochure
Bus/Train Ads
Dept of Mental Health
Faith-based Leader
Friend/Relative
Internet/www
Magazines/Newsletter
Newspaper
Other Crisis Hotline
Pens/Magnets/Giveaways












Posters
Radio
School
Spouse/Significant Other
Therapist/Counselor
TV
Wallet Card
Word of Mouth
Yellow Pages (Phone book)
Other
Specify:_____________________
 Do not remember

17. We understand that you called (# called). Had you ever called this crisis hotline before
(date of call)?
 Yes
 No
If “Yes,”
17a. How many times have you called (# called)?
 Once or twice
 Occasionally but not a lot
 All the time

Caller feedback on crisis call—the time caller called the center
17b. Thinking back to your call on (date of call) to (# called), were there things about the
call that were helpful to you?
 Yes
If “Yes,” details:

 No

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17c. Were there things about the call that were not helpful to you?
 Yes
If “Yes,” details:

 No

PRIOR SERVICE USE
So the next couple of questions I’m going to ask you are about the resources you used
BEFORE your call to the crisis hotline on (date)
18. Had you ever used any of the following services before you called the crisis hotline?
(read service list below to caller)
 Yes (If yes, check all service types that caller had used)
 Emergency Service (e.g., ER, mobile crisis)
 Phone Counseling / Crisis Hotline
 Professional Mental Health Service (e.g., psychiatrist, psychologist, social worker)
 Other Counseling Service (e.g., AA, pastoral counselor, support group)
 Other Professional Resource (e.g., pc doctor consulted for mental health issue)

 No (If “No,” skip to question #20.)

If “Yes,” 18a. When did you last use the service(s)?
(For each service used, code most recent date accessed BEFORE calling hotline.)
Last Time Accessed Service
Within
More than
Month
Within Year
One Year
Before Call
Before Call
Before Call
 Emergency Service







 Phone Counseling







 Professional Mental Health Service







 Other Counseling Service







 Other Professional Resource







19. Were you in treatment for any behavioral or emotional issues at the time you called
the hotline?
 Yes
 No
Page 4

If “Yes,”
19a. From whom were you receiving treatment? (Code all that apply):






Psychiatrist, psychologist, social worker
Other counselor
Other medical doctor
Clergy
Other If “Other”, specify: _______________________________

SUICIDE RISK – AT TIME OF CRISIS CALL
20. When you called the crisis hotline on (date of call), were you having any thoughts
about suicide.
 Yes  No
Details (including precipitating factors if mentioned):

21. At that time (when you called the crisis hotline), had you made any specific plans to kill
yourself, to end your life?
 Yes
 No
 Do not remember

If “No” or “Do not remember,” skip to question #22.

If “Yes,”
21a. What had you planned to do to kill yourself?

22. Had you done something to kill yourself right before you called the crisis hotline on
(date of call), or while you were speaking with the counselor?
 Yes
 No If “No,” skip to #23.
If “Yes,”
22a. What had you done to kill yourself? _____________________________
22b. (Interviewer: please classify actions based on caller’s response to #22a.)
 Preparatory behavior—not imminent risk (i.e., obtained method but NOT ready to use
now or very soon)

Page 5

 Preparatory behavior—imminent risk (i.e., standing on bridge ready to jump, have gun
& prepared to use now or soon)
 Attempt in progress—actual behavior to kill self without dire consequences (i.e.,
superficial cut then stopped)
 Attempt in progress—injury serious or potentially serious (i.e., shot self, cut self, took
pills)
22c. Do you think you were at risk of dying at the time of your call?
 Not at all

 A little

 Moderately

 A lot

PREVIOUS ATTEMPTS (EVER)
23. Have you ever, in your whole life tried to kill yourself?
(Interviewer note: if caller answered “Yes” to #22, code 23 as “yes”, and specify that this question
(23a) is about an attempt “other than what you just told me?”)
 Yes
 No If “No,” skip to question #28.
If “Yes,”
23a. Did you make the attempt BEFORE you called the crisis hotline on (date of call)?
 Yes
 No If “No,” skip to question #28.
If “Yes,”
23b. How many times did you try to kill yourself BEFORE you called the crisis
hotline? ______ times
24. When was your last attempt BEFORE you called the crisis hotline, (the one closest in
time to your call to the crisis hotline)?






Within 1 hour
Same day
Within 1 week
Within 1 month
More than 1 month

25. Did you go to a doctor, emergency room or other health facility for the resulting illness
or injury after you tried to kill yourself?
(Ask question within context of most recent attempt BEFORE calling crisis hotline)
 Yes
 No
If “Yes,”
25a. Who took you?
(ask question within context of most recent attempt BEFORE calling crisis hotline)
 Mobile Crisis
 Police
 Friend/family member
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 Self
 Other _______________________________________
26. What had you done to try to kill yourself?
(Ask question within context of most recent attempt BEFORE calling crisis hotline)
(Code: How? When? Where?)

27. If more than 1 attempt BEFORE calling crisis hotline, code up to 3 more attempts,
starting with the second most recent attempt BEFORE calling crisis hotline:
(For each attempt code: How? When? Where?)

28. When you called the crisis hotline on (date of call), how much would you say you wanted
to die?






Definitely wanted to die
Wanted to die more than live
About equal
A part of me wanted to live more than die
Definitely wanted to live

29. Did you think you had any other ways to solve your problems, other than suicide?
 Suicide was the only possible option
 Other possible options existed
30. When you called the crisis hotline, how likely were you to carry out your thoughts about
killing yourself?






1 = Not at all likely
2
3 = Somewhat likely
4
5 = Extremely likely

CALL EVALUATION
30a. How much did calling the crisis hotline stop you from killing yourself?
 A lot

 A little

 Not at all

 It made things worse

Details: What was it about the call that…?
Page 7

30b. How much did calling the crisis hotline keep you safe?
 A lot

 A little

 Not at all

 It made things worse

Details: What was it about the call that…?

FOLLOW-UP
The next questions are about the follow-up call(s) you received from the crisis center, after
your call to the hotline (# called) on (date of crisis call).
31. When was the last time you received a call from a counselor at the center?






Within the last few days
Within the past week
Within the past two weeks
Within the past month
More than a month ago

32. Are you expecting another call from the center?
 Yes, follow-up is on-going
 No, follow-up has ended
 Caller unsure
If “No”: 32a. Why did the center stop calling you for follow-up?
 Caller & center mutually agreed to end follow-up (i.e., because caller felt
better/was in treatment, or because all planned calls had been completed)
 Center unilaterally ended follow-up (i.e., center did not offer any more calls)
 Caller unilaterally ended follow-up (i.e., caller declined any more calls)
 N/A (Follow-up is on-going)
 Caller unsure whether follow-up has ended
33. Since you called the hotline on (date of crisis call), how many times have you spoken
with a counselor/counselors who called from (crisis center) to follow up with you?
 1x

 2x

 3x

 More than 3x (give #: _________)

34. How many different counselors made follow-up calls to you?
1

2

 More than 2 (give #: ________)

 Don’t remember

If caller had contact with more than one counselor from center:
34a. How did you feel about talking to different counselors?
 Comfortable

 Neutral

 Uncomfortable

35. Were there things about the follow-up call(s) from the crisis center that were helpful to
Page 8

you?
 Yes If “Yes,” details: ______________________________________________
 No
36. Were there things about the follow-up call(s) from the crisis center that were not helpful
to you?
 Yes

If “Yes,” details:_____________________________________________

 No

Page 9

COUNSELOR BEHAVIOR
37. Next, I want to ask you some specific questions about the counselor(s) from the crisis
center who followed up with you.
(Read the response options before starting, and repeat every several questions)

COUNSELOR BEHAVIOR (Rate Each Item)

Check below if caller
had multiple follow-up
counselors, and wants
to rate them differently
on a particular
behavior. (Do not read
this option to caller.)

Not
at
all

A
little

Moder
ately

A
lot

0

1

2

3

9

0

1

2

3

9

0

1

2

3

9

0

1

2

3

9

0

1

2

3

9

0

1

2

3

9

0

1

2

3

9

0

1

2

3

9

0

1

2

3

9

0

1

2

3

9

0

1

2

3

9

0

1

2

3

9

0

1

2

3

9

0

1

2

3

9

0

1

2

3

9

I. GOOD CONTACT:
To what extent did the counselor(s)
Show empathy or validate you by saying things like
“it must be hard for you”?
To what extent did the counselor(s)
Reflect back your feelings
To what extent did the counselor(s)
Paraphrase your situation?
To what extent did the counselor(s)
Create a caring and safe climate?
To what extent did the counselor(s)
Use a warm and genuine tone?
To what extent was/were the counselor(s)
Non-judgmental and accepting?
To what extent was/were the counselor(s)
Respectful to you?
To what extent was/were the counselor(s)
Patient with you? Did not rush you?
To what extent did the counselor(s)
Stay engaged?
To what extent did the counselor(s)
Use questions, reflections or other invitations that
deepened the relationship and understanding
between the two of you?
To what extent was/were the counselor(s)
Authentic and genuine?
To what extent did the counselor(s)
Sound natural not scripted??
To what extent did the counselor(s)
Use self-disclosure only when appropriate?
To what extent did the counselor(s)
Exhibit trust, competence and confidence?
To what extent did the counselor(s)
Not jump prematurely to problem solving?

Page 10

COUNSELOR BEHAVIOR (continued)

COUNSELOR BEHAVIOR (Rate Each Item)

Check below if caller
had multiple followup counselors, and
wants to rate them
differently on a
particular behavior.
(Do not read this
option to caller.)

Not
at
all

A
little

Moderately

A
lot

0

1

2

3

9

0

1

2

3

9

0

1

2

3

9

0

1

2

3

9

0

1

2

3

9

0

1

2

3

9

0

1

2

3

9

II. COLLABORATIVE PROBLEM SOLVING:
To what extent did the counselor(s)
Help you identify and prioritize problems, needs
and wants?
To what extent did the counselor(s)
Identify the event that precipitated your calling the
crisis hotline on (date of original call)?
To what extent did the counselor(s)
Explore what you had tried to do to solve the
problem?
To what extent did the counselor(s)
Try to solve your problems for you by telling you
what you should do?
To what extent did the counselor(s)
Explore (brainstorm) alternatives?
To what extent did the counselor(s)
Work with you to create a plan that will work for
you?
To what extent did the counselor(s)
Not jump prematurely to solutions?

Counselor Behavior in Assessing Suicide Risk:

During the follow-up calls, did the counselor(s)……

Yes

No Do Not
Remember

Ask you if you were thinking about suicide?







Ask you if you had any thoughts of suicide in the last two months?







Ask you if you have ever attempted suicide?







Ask any other kind of questions or make any other comments that
encouraged you to acknowledge that you were having thoughts
about suicide?







Page 11

Counselor Behavior in Assessing Client’s Buffers:
Yes

No

During the follow-up calls, did the counselor(s)……

Do Not
Remember

Talk with you about your plans for the future?







Talk with you about your reasons for living?







SUICIDE RISK DURING FOLLOW-UP PERIOD
These questions are about the time when (crisis center) was following up with you, between
your call to the hotline on (date of call) and the most recent follow-up call you received.
38. Between your initial call to the hotline on (date) and the most recent follow-up call you
received on (date), would you mind telling me if you have had any thoughts about killing
yourself or ending your life?
 Yes
If “Yes,” details:

 No
39. Did you do anything to kill yourself after you called the hotline, during the time the center
was following up with you?
 Yes
 No If “No,” skip to #40.
If “Yes,”
39a. What had you done to kill yourself?

Page 12

39b. (Interviewer: please classify actions based on caller’s response to #39a.)
 Preparatory behavior—not imminent risk (i.e., obtained method but was NOT ready to
use right away)
 Preparatory behavior—imminent risk (i.e., stood on bridge ready to jump, had gun &
was prepared to use)
 Suicide attempt—actual behavior to kill self without dire consequences (i.e., superficial
cut then stopped)
 Suicide attempt—injury serious or potentially serious (i.e., shot self, cut self, took pills)
39c. Do you think you were at risk of dying at that time?
 Not at all

 A little

 Somewhat

 A lot

40. To what extent did the counselor’s calling you stop you from killing yourself?
 A lot

 A little

 Not at all

 It made things worse

40a. Details: What was it about the follow-up calls…?

41. To what extent did the counselor’s calling you keep you safe?
 A lot

 A little

 Not at all

 It made things worse

41a. Details: What was it about the follow-up calls…?

42. When the counselor(s) called you to follow up with you, did you and the counselor(s)
develop a plan for what you could do to keep yourself safe?
 Yes
 No
 Do not remember
42a. Comments/clarification by follow-up interviewer and/or caller about safety plan:

Page 13

NOTE: If caller volunteers that a particular strategy was discussed ONLY during the initial crisis call (NOT during follow-up),
check “CC only,” then ask Q45.
43. During the call(s) with the counselor(s):
Did you and the counselor(s) talk about:

Yes

No

Do not
remember

CC
only

If Discussed:
If Used:
43a. Have you
43a. Has this
made use of
been helpful to
this, put it into
you?
practice?
Yes No N/A Yes No N/A

If NOT Used:
43c. What was the reason
you did not end up using
this?
Didn’t
think it
would
help

Need
did
not
arise

Other

N/A

reason*

Steps you can take to make your
environment safe (i.e., to get rid
of potential means to suicide)?





























“Safe use” or no use of alcohol
or drugs?





























Self-care or coping strategies?
(Things you can do on your own,
like listening to music, taking a
walk, taking a bath)





























Making sure you are not alone?





























Remembering things that have
helped you in the past (past
survival skills), to use again
now?





























*43d) (Interviewer: If “Other reason” is checked above for any step/strategy, please describe client’s reason for not using):

43e) Interviewer: After finishing the above chart, ask: Was there anything else that you came up with that has been helpful to
you (helped keep you safe) since you called the hotline?

Page 14

In this next section, we’re going to talk about some informal or social resources that you and the counselor(s) might have
discussed. Just to clarify, these aren't professional resources.
44) When the counselor(s) called to follow up with you, did you and the counselor(s) identify any informal or social resources
for you to use in times of crisis – for example, places you can go to not feel alone, or people who can help distract you if
you are feeling suicidal, or people like friends or family members whom you can ask for help?
 Yes

 No

 Do not remember

45) Specifically, did you and
the counselor(s) talk about:

If Discussed:

If Used:

If NOT Used:

45a) Have you
45b) Has this
45c) What was the reason
made use of
been helpful to
you did not end up using these
any of these
you?
resources?
resources?
Yes No N/A Yes No
N/A
Didn’t
Need
Other
N/A
think it
did
reason*
would
not
help
arise

Yes

No

Do not
remember

Places you can go to distract
yourself / not be alone?



























People to call socially, to
distract you if you are feeling
suicidal?



























People you can share feelings
with / ask for help? (not
including professional
caregivers)



























*45d) (Interviewer: If “Other reason” is checked above for any resources, please describe client’s reason for not using:

Page 15

45e. Informal/Social Safety Resources identified include: (check all that apply)
 Family member(s)
 Friend(s)
 Other people; Please specify: __________________________________________
 Social environment(s); Please specify: ___________________________________
45f. Did the follow-up counselor make phone calls to any of these people, to help you make
contact with them?
 Yes
 No
 N/A
FORMAL RESOURCES explored/identified:
46. OK, so in this section, we’re going to talk about any formal or professional sources of help that
you might have discussed with the counselor(s).
(Interviewer: Read resources below and if the caller says YES, check the box to the left of the resource;
then proceed to the sub-questions, if any.)
 Formal/Professional Resources
ASK: Did you and the counselor(s) talk about using any inpatient or outpatient mental heal
services (like a psychiatrist or a psychologist or a social worker)?
 Licensed Mental Health Professionals
(i.e., psychologist, psychiatrist, social worker, in/outpatient mh)
 New
 Current
 Prior
If yes, what type? __________________________________
ASK: Did you and the counselor(s) you spoke to discuss using other support services like
a support group, a 12-step program, a pastor or rabbi, or a healer?
 Mental Health Support Services (unlicensed)
(e.g., support groups like AA; school counselor/EAP; pastor/rabbi; native healer)
 New
 Current
 Prior
If yes, what type? __________________________________
ASK: Did you and the counselor(s) speak about using other resources, like a primary care
physician for a mental health issue, or any other professional assistance?
 Other Professionals (licensed in non-mental health fields)
(e.g., primary care physician, social services, other)
 New
 Current
 Prior
If yes, what type? __________________________________
If yes to any: Did counselor facilitate the contact by making a phone call?
 Yes  No  Don’t remember  N/A
Page 16

 Urgent Care/Emergency Resources
ASK: And with the crisis hotline, were you advised to call back the center? ASK
BOTH subheadings
 Crisis hotline/Crisis center
 Caller advised to call back center
 Crisis hotline or center OTHER than the one doing follow-up
ASK: And did you and the counselor(s) talk about using any urgent care or emergency
resources, such as the ER, 911, or EMS?
 Emergency Resources not including hotlines
 Emergency Room/Urgent Care facility
 EMS/Mobile Crisis
 911/Police
 Other: _________________________
If Yes to any: Did counselor make a phone call to help you make contact with them?
 Yes  No  Do not remember  N/A
Interviewer:
If caller received no referrals to a formal resource not already/currently in use by caller (i.e., no NEW or
PRIOR professional resources, and no emergency resources other than the current hotline/center), skip to
question #49.
If caller received any referral to a NEW or PRIOR professional resource, or to an emergency resource other
than the current hotline or center, continue to question #47.
These questions are about the referrals you and the counselor(s) discussed.
You mentioned that you and the counselor(s) discussed ___________ (for NEW referrals).
47. Did the counselor(s) help you envision or imagine what it would be like for you to make
contact with the professional(s) or service(s) you discussed?
 Yes

 No

 N/A (no NON-CURRENT formal/professional referral)

48. Did you and the counselor(s) problem-solve about what might keep you from contacting the
professional(s) or service(s) you discussed?
 Yes

 No

 N/A (no NON-CURRENT formal/professional referral)

“These next questions are going to be about your safety plan, by which I mean all the strategies and
resources you and the counselor(s) came up with for you to use to keep yourself safe.”
The comments/clarification by follow-up interviewer and/or caller about safety plan, when
caller was asked earlier in the interview question #43 about the developed safety plan:

Page 17

49. Did you and the counselor rehearse or walk through the steps and/or resources you were
going to use to help keep you safe – to make sure you remembered and felt comfortable
using them?
 Yes
 No
 N/A
49a. If there was any part of your safety plan that you felt uncomfortable with, did the
counselor(s) help you to overcome your discomfort, or help you to come up with a
different safety plan instead?
 Yes
 No
 N/A
50. Overall, how was the safety plan developed?





Collaborative development
You developed most of the plan
Counselor developed most of the plan
N/A – Safety plan not developed

51. Did you and the counselor(s) talk about using your safety plan again in the future?
(e.g., writing it down and keeping it in case you ever feel suicidal again, after your current
crisis had passed)
 Yes
 No
 N/A
51a. Did you write your safety plan down?
 Yes
 No
 Don’t remember
If Yes:
51b. Do you know where it is now?
 Yes (I still have it and know where it is)
 No (I don’t know where it is)
 I know that I don’t have it anymore
52. Did you and the counselor(s) talk about how you would know when it was time to use your
safety plan?
 Yes
 No
 N/A

Page 18

53. Did you and the counselor(s) identify any warning signs of emotional distress-- in other
words, thoughts, feelings or behaviors that can alert you the next time you are at risk,
before the problems get big or out of control?
 Yes
 No
 Do not remember

If “Yes”, 53a. Has being aware of this been helpful to you?
 Very much

 Somewhat

 A little

 Not at all

 N/A

54. Did you and the counselor(s) identify any events or situations which might trigger you to
become suicidal again in the future?
 Yes
 No
 Do not remember
If yes: 54a. Has being aware of this been helpful to you?
 Very much

 Somewhat

 A little

 Not at all

 N/A

55. Did you and the counselor(s) problem-solve to try to find other ways of addressing
or preventing your trigger events or situations?
 Yes
 No
 Do not remember
If Yes:

55a. Has this been helpful to you?

 Very much

 Somewhat

 A little

 Not at all

 N/A

Interviewer note: If no safety plan, go to question #56.
56. Overall, how helpful to you has your safety plan been?
 Very helpful



Somewhat
helpful



A little
helpful



Not at all
helpful



N/A – no
safety plan

57. What about your safety plan has been most helpful to you?

58. What about your safety plan has been least helpful to you?

Page 19

59. You said that you and the counselor(s) discussed _______________ (referral/s received).
Have you been able to call, contact, or follow through with (any of) the service(s) you and
the counselor(s) discussed?
 Yes
 No

Interviewer: read list of resources checked “yes” as discussed….and ask if used or not used
59a. Resource used or not?

Crisis hotline services
Urgent care/Emergency services (not including hotlines)
Licensed Mental Health Professionals
Mental health support / counseling (not licensed)
Other professional help; describe: _____________________

Discussed*
With
counselor(s)






Used
since

Not
used













*The computer program automatically codes the Resource Type “discussed” as “yes”, when it is endorsed
as “yes” by the caller earlier in the interview.
These next questions are about any services you may have used, whether or not you discussed
them with the counselor(s). Since you called the crisis hotline on (date of call), have you used or
made contact with any of the following services or resources?
(Interviewer: code all service types endorsed in #59a [referral follow-through], as well as any other service
types the caller has used since the crisis call. If more than one service used for a specific type of service,
rate the one of each type with the most complete follow through.
(Interviewer: If NO formal/professional resources utilized since crisis call, skip to #82.)
60.  Hotline Services

Specify:____________________

 Completed contact as follows: (check all that apply)
 Called back same hotline/center
 Accepted follow-up call from crisis center
 Called different hotline / phone counseling at different center

If yes, go to #61.

 Called/Received message but not yet able to speak to anyone – If yes, go to #62.


Called/received & found out that I can't, or
don't want to use this service

If yes, go to #63.

61. How much have you benefited from this service in your opinion?





Had a negative impact
No benefit/impact
Some benefit
A great benefit
Page 20

62. How well do you think this service matches your needs?
 Not well
 Somewhat well
 Very well
(Interviewer - if hotline services used, check box for “Services free” below)
 Services free
63.  Other Emergency Services Specify:____________________
 Completed contact as follows: (check all that apply)
 Presented at Emergency Room/Urgent Care facility
 Rescued by EMS/Mobile Crisis
 Rescued by 911/Police
 Called/presented & found out that I can't, or
don't want to use this service

If yes, go to #64.

If yes, go to #67.

64. How much have you benefited from this service in your opinion?





Had a negative impact
No benefit/impact
Some benefit
A great benefit

65. How well do you think this service matches your needs?
 Not well
 Somewhat well
 Very well
66. Who will pay or has already paid for this service?
(Code all that apply.)






Private insurance (Not HMO)
An HMO or other prepaid plan
Medicaid
Medicare
Any other government program, such as CHAMPUS or the Indian Health
Services
 You or your family
 Any other sources If “Yes,” Specify:____________________
 Services free
67.  Mental Health Services

Specify:____________________

 Kept more than one appointment
 Completed first appointment





If yes, go to #68.

Completed intake
Have an appointment set up
Called/Spoke with someone waiting for appoint – willing to wait
Called/Call not yet returned/Not yet able to speak with anyone

If yes, go to #70.

 Called & found out that I can’t, or don’t want to use this service — If “Yes,” go to #72.

Page 21

68. Are you still in treatment?

 Yes

 No

69. How much have you benefited from this service in your opinion?





Had a negative impact
No benefit/impact
Some benefit
A great benefit

70. How well do you think this service matches your needs?
 Not well
 Somewhat well
 Very well
71. Who will pay or has already paid for this service? (Code all that apply.)






Private insurance (Not HMO)
An HMO or other prepaid plan
Medicaid
Medicare
Any other government program, such as CHAMPUS or the Indian Health
Services
 You or your family
 Any other sources If “Yes,” Specify:____________________
 Services free
72.  Other counseling/support services

Specify:____________________

 Kept more than one appointment / attended
more than one session
 Completed first appointment / attended first session





If yes, go to #73.

Completed intake
Have appointment set up
Called/Spoke with someone/Waiting for call back (willing to wait)
Called/Call not yet returned/Not yet able to speak with anyone

If yes, go to #75.

 Called & found out that I can’t, or don’t want to use this service—If “Yes,” go to #77.
73. Are you still in treatment / still participating?

 Yes

 No

74. How much have you benefited from this service in your opinion?





Had a negative impact
No benefit/impact
Some benefit
A great benefit

75. How well do you think this service matches your needs?
 Not well
 Somewhat well
 Very well

Page 22

76. Who will pay or has already paid for this service? (Code all that apply)






Private insurance (Not HMO)
An HMO or other prepaid plan
Medicaid
Medicare
Any other government program, such as CHAMPUS or the Indian Health
Services
 You or your family
 Any other sources If “Yes,” Specify:_______________________
 Services free
77.  Other Formal/Professional Resource

(Please specify: _____________________)

 Kept more than one appointment
 Completed first appointment/attended first session





If yes, go to #78.

Completed intake
Have an appointment set up
Called/Spoke with someone/Waiting for call back (willing to wait)
Called/Call not yet returned/Not yet able to speak with anyone

If yes, go to #80

 Called & found out that I can’t, or don’t want to use this service — If “Yes,” go to #82.
78. Are you still in treatment?

 Yes

 No

79. How much have you benefited from this service in your opinion?





Had a negative impact
No benefit/impact
Some benefit
A great benefit

80. How well do you think this service matches your needs?
 Not well
 Somewhat well
 Very well
81. Who will pay or has already paid for this service? (Code all that apply.)






Private insurance (Not HMO)
An HMO or other prepaid plan
Medicaid
Medicare
Any other government program, such as CHAMPUS or the Indian Health
Services
 You or your family
 Any other sources If “Yes,” Specify:____________________
 Services free

Page 23

82. What type of health insurance do you have, if any?








No insurance
Private Insurance (Not HMO)
HMO or other prepaid plan
Medicaid
Medicare
Any other government program, such as CHAMPUS or the Indian Health Services
Other: ____________________________

Barriers to Service Use
83. Interviewer: Did the counselor discuss resources with the caller that s/he was not able to follow
through on, or decided not to use?
 Yes
 No

If “yes, go to question #84
If “no”, go to question #85

84. You said that you and the counselor discussed ______(referral), but that you didn’t use it.
Would you mind telling me the reasons why you didn’t use this?
(Code for each resource marked “discussed” and “not used”).
 Hotline Services
 Structural Barriers (e.g., no phone, no privacy)
Details: ____________________________________________________________
 Perceptions about Mental Health Problems (e.g., thought could handle on own)
Details: ____________________________________________________________
 Perceptions about Services (Past negative experience with provider(s); Bad initial contact with
staff)
Details: ____________________________________________________________
 Any other types of barriers:
Details: ____________________________________________________________
 Urgent Care/ Emergency Services (other than hotlines)
 Structural Barriers (e.g., long waiting line, transportation issues)
Details: ____________________________________________________________
 Perceptions about Mental Health Problems (e.g., thought could handle on own)
Details: ____________________________________________________________
 Perceptions about Services (Past negative experience with provider(s); Bad initial contact with
staff)
Details: ____________________________________________________________
 Any other types of barriers:
Details: ____________________________________________________________

Page 24

 Licensed Mental Health Professionals
 Structural Barriers (e.g., long waiting list, no health insurance, transportation issues)
Details: ____________________________________________________________
 Perceptions about Mental Health Problems (e.g., thought could handle on own)
Details: ____________________________________________________________
 Perceptions about Services (Past negative experience with MH provider(s); Bad initial contact
with staff)
Details: ____________________________________________________________
 Any other types of barriers:
Details: ____________________________________________________________
 Other counseling services/ support groups
 Structural Barriers (e.g., long waiting list, no health insurance, transportation issues)
Details: ____________________________________________________________
 Perceptions about Mental Health Problems (e.g., thought could handle on own)
Details: ____________________________________________________________
 Perceptions about Services (Past negative experience with provider(s); Bad initial contact
with staff)
Details: ____________________________________________________________
 Any other types of barriers:
Details: ____________________________________________________________

 Other Professional Resource(s)
 Structural Barriers (e.g., long waiting list, no health insurance, transportation issues)
Details: ____________________________________________________________
 Perceptions about Mental Health Problems (e.g., thought could handle on own)
Details: ____________________________________________________________
 Perceptions about Services (Past negative experience with provider(s); Bad initial contact
with staff)
Details: ____________________________________________________________
 Any other types of barriers:
Details: ____________________________________________________________

Page 25

Center for Epidemiologic Studies Depression Scale (CES-D), NIMH
85. Next, I'm going to read some statements of feelings and behaviors.
Please tell me how often you have felt this way during the past week.
(Interviewer: Read the response options before starting, and repeat every several questions)
Rarely or none
of the time
(less than 1
day)

Some or a
little of the
time
(1–2 days)

Occasionally or
moderate
amount of time
(3–4 days)

Most or all
of the time
(5–7 days)

I was bothered by things that
usually don't bother me.
I did not feel like eating; my appetite
was poor.
I felt that I could not shake off the
blues even with help from my family
or friends.
I felt I was just as good as other
people.
I had trouble keeping my mind on
what I was doing.









































I felt depressed.









I felt that everything I did was an
effort.









I felt hopeful about the future.









I thought my life had been a failure.









I felt fearful.









My sleep was restless.









I was happy.









I talked less than usual.









I felt lonely.









People were unfriendly.









I enjoyed life.









I had crying spells.









I felt sad.









I felt that people dislike me.









I could not get “going”.









Page 26

Ideation, Behavior, and Risk Since Last Contact With Crisis Counselor
Okay, so these next questions are about how you’ve been feeling since the last time a
counselor called to follow up with you. Just to let you know, they are mostly yes or no
questions.
86. Since the last time you spoke with a follow-up counselor, have you had any thoughts about
killing yourself?
 Yes
 No
87. Right now, are you having any thoughts about killing yourself?
 Yes
 No (If “No,” go to #88).
If “Yes,”
87a. How much of each day have you been thinking about suicide?
 Fleeting thoughts/Once in a while
 Persistent thoughts/A lot of the time
87b. Have you been able to control your thoughts about suicide?
 Yes
 No
88. Since the last time you spoke with a follow-up counselor, have you had any plans to kill
yourself?
 Yes
 No
89. Right now, do you have any specific plans to kill yourself?
 Yes* If “Yes,” continue to Question 89a.
 No
If “No,” go to question 92.
89a. What do you plan to do to kill yourself?
(Code: How? When? Where?)

89b. Is this means available to you?
 Not available/Has not been obtained
 Close by/obtained, but is not readily available
 Has on hand/ready to use/immediately available

Page 27

89c. When are you planning to do it?
 Immediately*
 Within a few hours*
 Within a few days
 Within a week
 Within the month
 Some indefinite time in the future
89d. Are you alone now?
 Yes
 No

If No, go to #90

89e. Is anyone nearby?
 Yes
 No
90. Have you been drinking or taking (illicit) drugs today?
 Yes
 No If No, go to #91
If Yes: 90a. How much/what kind? ___________________________________________
If they haven’t already mentioned firearms as a part of their plan, ask; if already mentioned, code
without asking:
91. Are there any firearms available where you are now?
 Yes
 No
92. Have you done anything to kill yourself since the last time a counselor called to follow up with
you?
 Yes* If “Yes,” continue to #92a.
 No
If NO attempt post-f/u, but has current thoughts  go to #97.
If NO attempt post-f/u, and NO current thoughts  go to #100.
If “Yes”:
92a. What had you done to kill yourself?

Page 28

92b. (Interviewer: please classify actions based on caller’s response to #92a.)
 Preparatory behavior—not imminent risk (i.e., obtained method but was NOT ready to use right
away)
 Preparatory behavior—imminent risk (i.e., stood on bridge ready to jump, had gun & was
prepared to use)
 Suicide attempt—actual behavior to kill self without dire consequences (i.e., superficial cut then
stopped)
 Suicide attempt—injury serious or potentially serious (i.e., shot self, cut self, took pills)
92c. Do you think you were at risk of dying at that time?
 Not at all

 A little

 Somewhat

 A lot

93. When was your last attempt AFTER your last follow-up call from a counselor at the
crisis center?
 Within 1 hour of last follow-up contact with counselor
 Same day
 Within 1 week after the follow-up contact
 Within 1 month after the follow-up contact
 More than 1 month after the last follow-up contact
Interviewer: (Ask these questions within context of most recent attempt AFTER last follow-up contact)
94. Did you go to a doctor, emergency room or other health facility for the resulting
illness or injury after you tried to kill yourself?
 Yes
 No
95. Was EMS sent for you?
 Yes
 No
96. For the suicide attempt you made after your last follow-up call from the center,
did you receive treatment from the ER, a hospital, a mental health provider, an in-or
outpatient facility, a caseworker, or any other resource?
 Yes
 No*
Interviewer: If caller has current thoughts: Continue to Question #97.
If NO current thoughts: Go to Question #100.
97. Right now, when you think about killing yourself, how much do you really want to die?
 Definitely want to die*
 Want to die more than live*
 About equal
 A part of me wants to live more than die
 Definitely want to live

Page 29

98. Right now, do you think you have any other ways to solve your problems, other than suicide?
 Suicide is the only possible option
 Other possible options exist
On a scale of 1 to 5, where 1 is “not at all likely,” 3 is “somewhat likely,” and 5 is “extremely likely”:
99. Right now, how likely are you to try to kill yourself?
 1 = Not at all likely
2
 3* = Somewhat likely
 4*
 5* = Extremely likely
100. Thinking back about how you were feeling at the time you called the crisis hotline on
(date of initial call), and how you are feeling now, would you say you’re………..
(read all choices)






A lot worse
A little worse
About the same
A little bit better
A lot better

Page 30

Note: The information needed in order to send the money order to the caller is entered onto a paper form,
whereas the follow-up assessment is entered directly into a computerized database.
The interviewer summarizes the call with the caller (suggested wording for that summarization is detailed
in the following page).
The information needed for sending the money order to the caller is obtained.

Name:

Mailing Address:

First Name:_________________________
Middle Name:_______________________
Last Name:_________________________

Street: ____________________________
City: ______________________________
State: _____________________________
Zip Code: __________________________

The caller is thanked for his/her participation. If required, interviewer initiates conference call with
Caller and crisis counselor.
Conference Call Record:
Conference call required? (See summary on next page to see if caller meets criteria)
 Yes
 No
If “Yes”: Did caller agree to conference call?

 Yes

 No

Did you (interviewer) establish call with caller and crisis center
(during which caller and center agreed to reconnect once you got
off the line?  Yes
 No
If “No” :

Did caller agree to receive a call from the hotline at a later time/date?  Yes  No
If “Yes”: Did you (interviewer) contact hotline with the caller’s and
your (interviewer’s) contact information, so the center could
contact the caller in the future?  Yes
 No

MANDATORY CONFERENCE CALL:
If caller meets the criteria for the mandatory conference call, you must initiate a conference call with the
caller and the crisis center that has been conducting the follow-up calls with the caller.
If you encounter a busy signal, you can work with the caller a few minutes more and then try again,
or conference call with the caller to 1-800-273-TALK or 1-800-SUICIDE.

Page 31

Criteria for Mandatory Conference Call:
(1) The caller has made a suicide attempt since the most recent follow-up call from the center, and did not
receive any treatment after the attempt. If the caller has made more than one attempt since the most recent
follow-up call, then this criterion relates to the most recent attempt.
(2) The caller responds YES to any of the starred items under Current Plans/Means/Availability or under
Current Intent to Die.
Suggested Wording for Discussing Conference Call with the Caller:
During our call today, you've told me some things that I'm really concerned about. You said “(suicide
attempt since last follow-up contact, and no treatment, and/or list starred suicide items), “and that you're
feeling” (information from the CES-D. So, before we end our call today, it's important that I connect you
back to the crisis hotline so they can talk with you further about your thoughts about suicide, and the things
that you've been going through. What would happen is that I would conference call with you back to the
hotline. While you, the crisis counselor and I are on the phone together, I'd tell the counselor what you and I
spoke about today, and give the counselor enough information so he or she can help you. Then, I'd get off
of the line so you and the counselor can talk together.”
If the caller agrees to the conference call, keep the caller informed of exactly what you are doing. Tell
him/her:
“Okay, I'm going to set up the conference call now. To be able to do this, what I have to do is to put
you on hold while I dial the crisis hotline's telephone number. While I'm doing this, you won't hear
anything, but I'm still connected with you. After the hotline answers my call to them, then I will take
you off of hold, and the three of us will then be on the phone at the same time.”
If the caller agrees to speaking with the center, but cannot, does not want to do so via a conference call,
then call the crisis center, give the center your name and telephone number, the caller's name and
telephone number, and details about what the caller endorsed during the assessment.
IF THE CALLER REPORTS PROBLEMS BUT DOES NOT MEET THE CRITERIA for a mandatory
conference call, but might benefit from a crisis intervention call with the crisis hotline, then discuss this with
the caller.
Suggested Wording to Use With the Caller:
“During our call today, you told me that you are (information from CES-D, any endorsed suicide items, but
not starred ones), and that (list any other problems they mentioned). I am wondering if you might want to
call back (the # caller called - either 1-800-SUICIDE or 1-800-273-TALK) crisis line and speak with a
counselor to help you with the things you have been going through.
IF THE CALLER DOES NOT MEET CRITERIA FOR A CONFERENCE CALL AND DOES NOT REPORT
PROBLEMS:
Suggested Wording to Use With the Caller:
“From what you have told me today, you seem to be doing well since you called the crisis hotline. However,
if you ever want some help with a problem in the future, feel free to call the crisis hotline.”

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