Form Imminent Risk Form Imminent Risk Form Imminent Risk Form

OMB No. 0930-0333

Approval expires 01/31/2015

IMMINENT RISK FORM – COUNSELOR INFORMATION (This page is completed once per counselor.)

Your Name: __________________________________________ (Columbia will replace with an ID#)

Your Center: __________________________________________ (Columbia will replace with an 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: Date(s) of ASIST training: _______/ ___________ (mm/yyyy)

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

If yes: Date(s) of Safety Planning training: ________ / __________(mm/yyyy)

9. Have you made use of the Lifeline Simulation Training System (available on the Lifeline’s Network Resource Center website)? ☐ Yes ☐ No

If yes: How many times? ☐ <1 practice call ☐ 1-3 calls ☐ 4-6 calls ☐ >6 calls

10. 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 & Gregory Brown (available through SPRC and other sources)

☐ Other: _________________________________________

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

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

If yes: When did you begin conducting follow-up calls? ______ / _________ (mm/yyyy)

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

☐ Immediate safety check (within 48 hours of crisis call)

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

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

OMB No. 0930-0333

Approval expires 01/31/2015

IMMINENT RISK FORM – CENTER INFORMATION (This page is completed once per center.)

Your Center: __________________________________________ (Columbia will replace with an ID#)

1. Is your crisis line part of a larger behavioral health organization? ☐ Yes ☐ No

2. Please indicate what types of crisis services your organization includes, in addition to your crisis hotline(s):

☐Psychiatric Emergency Services Unit (PES) or other walk-in urgent care clinic

☐ Crisis Stabilization Unit (CSU) or other non-hospital residential crisis service

☐ Psychiatric hospital

☐ Mobile crisis team

☐ Assertive Community Treatment (ACT)

☐ Projects for Assistance in Transition from Homelessness (PATH)

☐Outpatient behavioral health services

☐Medical services

☐ Other (please describe):­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­ ______________________________________________________

☐ None of the above (i.e., stand-alone call center)

3. If your organization does not include a mobile crisis team, is there a mobile crisis team in your area which you can call/to which you can make referrals? ☐ Yes ☐ No

4. If your center has access to a mobile crisis team (whether belonging to your center or independent of your center), please describe that team below (check all that apply):

   1. Mobile team can be sent on an… ☐ emergency (w/in 2 hours) ☐ urgent (w/in 24 hours) …basis

   2. Mobile team has the capacity to transport an individual at risk to a hospital/ER? ☐ Yes ☐ No

   3. Mobile team includes and/or rides with the following: always sometimes never

Behavioral health clinician(s) (e.g., social worker) ☐ ☐ ☐

EMT ☐ ☐ ☐

Police or other law enforcement ☐ ☐ ☐

Psychiatrist ☐ ☐ ☐

Registered nurse ☐ ☐ ☐

Other (please describe below) ☐ ☐ ☐

:_______________________________________________________________________

OMB No. 0930-0333

Approval expires 01/31/2015

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

Center: ____________________ (Columbia will replace with ID#) FORM #:__________________

Counselor’s Name:_____________________________________ (Columbia will replace with ID#)

Call Date: ________________________ (mm/dd/yyyy)

1. Line Called:  Lifeline (regular line)  Lifeline (VA line)  Lifeline (chat)  Center’s local line  DK

If “DK” (Don’t Know), list first 6 digits of caller’s telephone #: ___________ _____________

(area code) (first 3 digits tel #)

2. Language Spoken:  English  Spanish  Other_______________

3. Who Participated in This Call?

a. Person at Imminent Risk:  Initiated call  Subsequently joined call  Not on call

b. Third Party:  Initiated call (calling about person at imminent risk)  Subsequently joined call  Not on call

4. Gender of Person at Imminent Risk:  Male  Female  Other ___________  Don’t know

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

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

 Yes  No

6. Has the person at risk ever served in the military?  Yes  No  Don’t know

If “Yes,” current military status:

 Active Duty  Reserve/National Guard  Veteran  Other ___________  Don’t know

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

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

8. 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  Don’t know Ability to control suicidal thoughts?  Yes  No  Don’t know

9. Suicidal Intent (please answer each question for person at imminent risk)

Yes No D/K

   Expressed intent to die

   Plan to kill self

   Method chosen

(If yes, please specify)  Cutting  Gun  Hanging  Pills  Other _____________

   Attempt in progress (if yes, skip to question #10)

   Preparatory behaviors (not including an attempt)

Timeframe for acting on thoughts (please specify)  Immediately/Within a few hours  Within a few days

 Within a week  Specific time over a week away  Indefinite future/Time not chosen  Don’t know

10. Suicidal Capability (please answer each question for person at imminent risk)

Yes No D/K    History of suicide attempts If “yes”, #:_____	Yes No D/K    Recent dramatic mood change
   Exposure to someone else’s completed suicide? If “yes”, Whose?_______________________	   Sleep problems (e.g., insomnia; increased or decreased sleep)
   History of violence to others	   Current intoxication
   Aggression/Anger (recent acts and/or threats)	   History of substance abuse
   Impulsive/Reckless behavior (current or past)	   Out of touch with reality (e.g., hearing voices)
   Agitation/restlessness
   Means available (If yes, please specify)  Immediately accessible  Available but not immediately accessible

11. 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  Don’t know

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

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

 Get rid of means

 Collaborate on safety plan

 Receive follow-up from your center

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

 Be taken to hospital/ER by a third party (e.g., family member or friend)

 Take him/herself to hospital/ER

 Contact emergency services (e.g., 911) on his/her own behalf

 Other: ______________________________________________________

13. With consent of person at imminent risk, you: (check all that apply)

 Contacted a third party (e.g., family member, friend, school counselor, etc.)

 Contacted a professional currently treating him/her

 Contacted the VA

 Contacted a mobile crisis/outreach team for (choose one):

 immediate evaluation (w/in 2 hrs)  urgent evaluation (w/in 24 hrs)  other: _______________

 Contacted emergency services (e.g., police, sheriff, EMS)

 Other: ______________________________________________________

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

 Contacted a third party (e.g., family member, friend, school counselor, etc.)

 Contacted the VA

 Contacted a mobile crisis/outreach team for (choose one):

 immediate evaluation (w/in 2 hrs)  urgent evaluation (w/in 24 hrs)  other: _______________

 Contacted emergency services (e.g., police, sheriff, EMS)

 Other: ______________________________________________________

15. Was imminent risk reduced enough so rescue was not needed? (i.e., person’s safety was secured without going to hospital/ER or involving emergency services such as police?)  Yes  No

16. Check here if you wanted to initiate rescue for this person (i.e., dispatch emergency services and/or have the person transported to the hospital/ER) but were unable to do so 

17. 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 obtain person at imminent risk’s collaboration on actions to be taken

 No way to determine location of person at risk (e.g., caller ID blocked, or caller using cell phone)

 Emergency services were contacted, but unable to dispatch

 Emergency services dispatched, but unable to make contact with person at imminent risk

 Other barriers encountered; Describe:___________________________________________

 N/A, no barriers encountered

18. Did you consult with your supervisor about this case during the call?  Yes  No

19. Did you consult with your supervisor about this case after the call?  Yes  No

QUESTIONS 20-22 – COMPLETE FOR ANY CALL INVOLVING A THIRD PARTY

20. QUESTIONS ABOUT THIRD PARTY PARTICIPATING IN CALL (IF ANY):

Person at Imminent Risk was Third Party’s … (please check one)  Child  Sibling  Spouse/Significant other  Other family member:_________________  Friend  Patient  Professional contact (e.g., student, co-worker, client)  Other:_________________________________	FOR THIRD PARTY CALLERS: 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’s Gender:  Male  Female  Don’t know Third Party’s Age:_________ (years)  Under 18  18 or over  Don’t know

21. Interventions Involving Third Parties Who Initiated or Participated in Call (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 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: ______________________________________________________

22. Barriers to collaborating with third party: (please check all that apply)

 Difficult to establish rapport with third party

 Third party unwilling or unable to help with intervention

 Third party wished or needed to remain anonymous

 Other barriers encountered; Describe:___________________________________________

 N/A, no barriers encountered

QUESTIONS 23-24 – COMPLETE FOR ALL CALLS

23. Steps taken to determine outcome of case (e.g., whether emergency services made contact with person at imminent risk, or whether s/he remained safe after the call): (check all that apply)

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

 Stayed on line with person at imminent risk while s/he went to the ER/hospital

 Attempted to re-contact person at imminent risk, after the end of the call

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

 Attempted to contact ER/hospital to determine arrival/disposition

 Attempted to contact mobile crisis/outreach team to determine status of evaluation

 Attempted to contact third party who took responsibility for person at imminent risk

 Attempted to contact professional responsible for care/treatment of person at imminent risk

 Other: ______________________________________________________

 N/A

24. What was the result of your attempts to follow up on/acquire information about the outcome of this case, after the end of the call?

Information was obtained from person at imminent risk  Yes  No  N/A, not attempted

Person at risk was reached by your center for clinical follow-up  Yes  No  N/A, not attempted

Information was obtained from public safety answering point  Yes  No  N/A, not attempted

Information was obtained from hospital/ER  Yes  No  N/A, not attempted

Information was obtained from mobile crisis/outreach team  Yes  No  N/A, not attempted

Information was obtained from third party  Yes  No  N/A, not attempted

Information obtained from person at risk’s treatment professional  Yes  No  N/A, not attempted

Other: ________________________________________________

QUESTION 25 – COMPLETE FOR ANY CALL WHERE emergency services (police, sheriff, EMS, ambulance) WERE CONTACTED and/or arrangements were made for transport to ER/HOSPITAL

25. What was the outcome of your contact with emergency services or other attempt to rescue person at imminent risk?

Emergency services (e.g., police, EMS) were dispatched  Yes  No  Don’t know  N/A

Emergency services (e.g., police, EMS) located person at risk  Yes  No  Don’t know  N/A

Person at risk arrived at ER/hospital  Yes  No  Don’t know  N/A

Person at risk was admitted to ER/hospital  Yes  No  Don’t know  N/A

Other: ________________________________________________

QUESTION 26 – COMPLETE FOR ALL CALLS

26. If any additional interventions were implemented with the person at imminent risk or involved third party after the end of this call (not including responses to subsequent crisis calls from the same person), please describe them here:

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

Counselor: At the beginning of the evaluation, you completed a Counselor Information Form which asked about your training and experience. If you have completed additional training since you completed that form, would you please complete the following. Thank you.

IMMINENT RISK FORM – ADDITIONAL COUNSELOR TRAINING

Counselor Name: __________________________________________ (Columbia will replace with an ID#)

Center Name: _____________________________________________ (Columbia will replace with an ID#)

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

Type of training:

☐ ASIST (Applied Suicide Intervention Skills Training) Date: _____/_____/_______ (mm/dd/yyyy)

☐ Other: ____________________________________ Date: _____/_____/_______ (mm/dd/yyyy)

☐ Other: ____________________________________ Date: _____/_____/_______ (mm/dd/yyyy)

☐ Other: ____________________________________ Date: _____/_____/_______ (mm/dd/yyyy)

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