SUICIDE RISK ASSESSMENT

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OMB No. 0930-0274
								Expiration Date:  XX/XX/XXXX

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 0930-0xxx.  Public reporting burden for this collection of information is estimated to average 40 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, 5600 Fishers Lane, Room 15E57-B, Rockville, Maryland, 20857.

Cohort V CLIENT FOLLOW-UP INTERVIEW
	Participant ID#: ______________
Date of ER visit / hospital inpatient admission:  ___  ___/  ___  ___  / ___  ___  ___  ___ (mm/dd/yyyy)
Crisis Center that conducted follow-up with client: 	
Center Code #: ______________________________________________________________________ 
Hospital referral came from?      Emergency department     Inpatient Unit  
                                                 Name of hospital:______________________________________  
Date of Research Follow-Up Interview: 	
Follow Up Interviewer's Name: 	

During this interview, I'll be asking you some questions to find out how you were doing when you went to the hospital on (date), and how you're doing now.  But, before I do that, I'd like to ask you a few questions about your background, 

    1. Age?__________

    2. Gender: 
    • Male
    • Female
    3. Ethnicity:
    • Hispanic or Latino
    • Not Hispanic or Latino
  
    4. How would you describe your race?  (Select all that apply)
    • American Indian/Alaska Native
    • Asian
    • Native Hawaiian or Other Pacific Islander
    • Black or African American
    • White
    • Don’t Know
    • Refused
    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.)
    6. Currently attending school?   
    • Yes      
    • No

      If “Yes,”
6a.	What type of school?   ___________
6b. 	Attending?   Full Time     Part Time
    7. Your father's 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.)
    • Don’t know
    8. Your mother's 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.)
    • 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

10.  Are you currently a member of the Reserves or National Guard?  
           Yes     No     Prefer not to answer

11.  Have you ever served in a combat zone or on a peace-keeping mission?
           Yes     No     Prefer not to answer

12.  Employment Status: (check all that apply)
    • Employed Full Time
    • Employed Part Time
    • Homemaker
    • Retired
    • Unemployed
  On Disability

13.  Are you currently (read choices)? 
    • Married
    • Separated
    • Divorced
    • Widowed
    • Never married
14. Are you currently living with
      someone in a marriage-like
      relationship?
    • Yes
    • No

15.  Household composition? (check all that apply)
    • Spouse/Partner
    • Children (If “Yes,” Number:_____)
    • Parent(s)
    • Other family Member(s)
    • Non-family Member(s)
    • Live alone

16.  How long have you lived at your
       current address?
                                     (circle unit of time)
___( # ) _____    days    months    years 
17.  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        
18. Do you have health insurance?
    • Yes
    • No

If “Yes,” What kind? 
    • Insured through employer (or other group plan)
    • Purchase own insurance policy
    • Covered on parent’s or spouse’s insurance plan
    • Medicaid
    • Medicare
    • Any other government program, such as CHAMPUS or the Indian Health Services
    • Other: ____________________________
PRIOR SERVICE USE

So the next couple of questions I’m going to ask you are about the resources you used BEFORE you went to the hospital on (date)

19.  Had you ever used any of the following services for a mental health issue BEFORE you went to the hospital?   (read service list below to client)
    • Yes (If yes, check all service types that client had used, and code most recent date accessed BEFORE going to the hospital)

    • Emergency Department for mh/bh issue
    • Inpatient Hospitalization for mental/behavioral health issue
    • Phone Counseling / Crisis Hotline
    • Other Emergency Service (e.g., 911, mobile crisis evaluation)
    • 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 #21.)

       If “Yes,”19a. When did you last use the service(s)?
              (For each service used, code most recent date accessed BEFORE going to the hospital.)


Last Time Accessed Service

Within Month Before Going to Hospital 
Within Year Before Going to Hospital
More than One Year Before Going to Hospital 
    • Emergency Department



    • Inpatient Hospitalization



    • Phone Counseling /Crisis Hotline



    • Other Emergency Service



    • Professional Mental Health Service



    • Other Counseling Service



    • Other Professional Resource




20.  Were you in treatment for any behavioral or emotional issues at the time you went to the hospital?
    • Yes
    • No
 
      If “Yes,” 20a. From whom were you receiving treatment? (Code all that apply):
    • MH professional (e.g., psychiatrist, psychologist, social worker)
    • Other counseling (e.g.,  clergy, support group, AA)
    • Primary care doctor (i.e., for medication management)
    • Other members of treatment team (e.g., case worker, occupational therapist)
    • Other     If “Other”, specify:  _______________________________
SUICIDE RISK – AT TIME OF HOSPITAL VISIT 

21.  When you went to the hospital on (date), were you having any thoughts about suicide? 
    • Yes
    • No
	
         Details (including precipitating factors) if mentioned:



22.  At that time (when you went to the hospital), had you made any specific plans to kill yourself, to end your life?
    • Yes
    • No							    If “No” or “Do not remember,” skip to question #24
    • Do not remember	

If “Yes,”

22a. Had you planned how to do it?
    • Yes
    • No	
    • Do not remember	
Details: ____________________________________

	If “Yes,”
22b. Were those means available to you?
    • Not available/Had not been obtained
    • Obtained/Close by, but not immediately available
    • Immediately available/On hand
    • N/A

22c. Had you planned where to do it?
    • Yes
    • No	
    • Do not remember	
Details: ____________________________________

22d. Had you planned when to do it?
    • Yes
    • No	
    • Do not remember	


	If “Yes,”
	22e. When did you plan to do it? 
                • Immediately / within a few hours
                • Within 48 hours
                • Within a week
                • Specific future date (more than a week away)
                • When things got bad enough
                • Other: _________________
                • N/A

23. Had you done something to preparefor killing yourself (e.g., obtaining means, writing a note)?
    • Yes
    • No	
    • Do not remember	
Details: ____________________________________

24.  Had you done something to try to kill yourself right before you went to the hospital on (date)?
    • Yes
    • No    If “No,” skip to #25.

	If “Yes,”
24a.	What had you done to kill yourself? _____________________________

24b. (Interviewer: please classify actions based on client’s response to #24a.)
    • Preparatory behavior (i.e., client obtained method, wrote a note)
    • Aborted attempt (i.e., client stood on bridge ready to jump, held gun to head, held pills in hand, put rope around neck, etc. – then changed his/her mind and didn’t go through with it)  
    • Interrupted attempt (i.e., same as aborted attempt, but somebody else or some external event prevented client from acting – client did not change his/her mind) 
    • Attempt in progress  (i.e., client shot self, cut self, took pills) 
    • NSSI (i.e., client cut self or otherwise self-harmed with no intent to die) 
	(Interviewer: If NSSI is checked, #24 should be coded “No.”)

24c.	Do you think you were at risk of dying when you went to the hospital? 

Not at all

A little

Moderately

A lot

25. When you went to the hospital on (date), 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

26. 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

27. When you went to the hospital, 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
    • 6  =   Did try to kill self

Automatically code “6” if behavior previously reported was Attempt in Progress (24b)

PREVIOUS ATTEMPTS (EVER) 

(Interviewer note: if client answered “Yes” to #24, code 28 as “yes”, and specify that the next question (28a) is about an attempt “other than what you just told me.”)

    28. Have you ever, in your whole life tried to kill yourself? 
    • Yes		
    • No     If “No,” skip to question #33

If “Yes,”
28a.	Did you make the attempt BEFORE you went to the hospital on (date)?
    • Yes
    • No     If “No,” skip to question #33

If “Yes,”
28b.	How many times did you try to kill yourself BEFORE you went to the hospital?     ______ times

29. When was your last attempt BEFORE you went to the hospital, (the one closest in time to your going to the hospital)?
    • Within 1 hour 
    • Same day 
    • Within 1 week 
    • Within 1 month
    • More than 1 month

30. 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 going to hospital)
    • Yes
    • No


31. What had you done to try to kill yourself?
(Ask question within context of most recent attempt BEFORE going to hospital)
(Code:  How?  When?  Where? Were you hospitalized?)



32. If more than 1 attempt BEFORE going to the hospital, code up to 3 more attempts, 
      starting with the second most recent attempt BEFORE going to the hospital: 
	(For each attempt code: How? When? Where? Were you hospitalized?)




FOLLOW-UP (by crisis center counselors)
The next questions are about the follow-up contact(s) you received from the crisis center,  after you were discharged from the (ED / Hospital) on (date).

		
33.  Since you were discharged from the (ED or Hospital) on (date), how many times have you been contacted by a counselor/counselors from (crisis center) for follow-up?
			 1x     2x     3x     More than 3x (give #: _________) 
	 Client does not remember receiving follow-up  (If yes, skip to question # 61)

34.  Were there things about the follow-up contact(s) from the crisis center that were helpful to you?
    • Yes     If “Yes,” details: ______________________________________________
    • No

35. Were there things about the follow-up contact(s) from the crisis center that were not helpful to you?
    • Yes    If “Yes,” details:_____________________________________________ 
    • No

36. What type of follow-up did you receive from the crisis center? (check all that apply)
    • Telephone call(s)
    • Chat follow-up
    • Text follow-up
    • Face-to-face contact with crisis counselor
Details (if provided): ____________________________________

Interviewer: for each type of follow-up the client received, ask the following:
	36a. How did you feel about receiving follow-up contact over the telephone?

Comfortable

Neutral

Uncomfortable

	36b. How did you feel about receiving follow-up contact over online chat?

Comfortable

Neutral

Uncomfortable

	36c. How did you feel about receiving follow-up contact by text?

Comfortable

Neutral

Uncomfortable

	36d. How did you feel about receiving follow-up contact in person?

Comfortable

Neutral

Uncomfortable

37. Which medium of follow-up did you (or would you) prefer?
    • Telephone call(s)
    • Chat follow-up
    • Text follow-up
    • Face-to-face contact with crisis counselor
Details: ____________________________________


38. How many different counselors contacted you for follow-up?
			 1     2     More than 2 (give #: ________)     Don’t remember

	If client had contact with more than one counselor from center:

38a. How did you feel about talking to different counselors?  

Comfortable

Neutral

Uncomfortable
 
39. When was the last time you were contacted by 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

40.  Are you expecting another contact from the center?
    • Yes, follow-up is on-going
    • No, follow-up has ended
    • Client unsure

If “No”:
40a. How did follow-up end?
    • Client & center mutually agreed to end follow-up (i.e., because client felt better/was in treatment, or because all planned contacts had been completed)
    • Center unilaterally ended follow-up (i.e., center did not offer any more contacts)
    • Client unilaterally ended follow-up (i.e., client declined any more contacts)
    • N/A (Follow-up is on-going)
    • Client unsure whether follow-up has ended
COUNSELOR BEHAVIOR

41.  Next, I want to ask you some specific questions about the counselor(s) from the crisis
       center who followed up with you.


COUNSELOR BEHAVIOR (continued)



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 thought about suicide within the past two months?





   Ask you if you had ever attempted suicide?





   Ask any other kind of questions 
   that encouraged you to acknowledge suicidal thoughts?





Counselor Behavior in Assessing Client’s Buffers:

During the follow-up calls, did the counselor(s)……
 Yes
 No
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, from the time you were discharged from the (ED / Hospital) on (date) to the most recent follow-up contact you received. 

42.  Between the time you were discharged from the (ED / Hospital) on (date) and the most recent follow-up contact you received, would you mind telling me if you were having any thoughts about killing yourself or ending your life? 
    • Yes     
                      If “Yes,” details: 

    • No 		

43. While you were receiving follow-up from the crisis center, did you have a specific plan to kill yourself?
    • Yes
    • No		
    • Do not remember					If “No” or “Do not remember,” skip to #44
Details: ____________________________________

	If “Yes,”
43a. Did you plan how to do it?
    • Yes
    • No	
    • Do not remember	
Details: ____________________________________

	If “Yes,”
43b. Were the means available to you?
    • Not available/Had not been obtained
    • Obtained/Close by, but not immediately available
    • Immediately available/On hand
    • N/A

43c. Did you plan where to do it?
    • Yes
    • No	
    • Do not remember	
Details: ____________________________________

43d. Did you plan when to do it?
    • Yes
    • No	
    • Do not remember	

	If “Yes,”
	43e. When did you plan to do it? 
                • Immediately / within a few hours
                • Within 48 hours
                • Within a week
                • Specific future date (more than a week away)
                • When things got bad enough
                • Other: ______________________________
                • N/A

44. Had you done something in preparation for killing yourself (e.g., obtaining means, writing a note)?
    • Yes
    • No	
    • Do not remember	
Details: ____________________________________

45. While the center was following up with you, 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

46. 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

47. While the center was following up with you, 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
    • 6  =   Did try to kill self  (If yes, check yes to question #48 below and skip to #48a)

48. Did you do anything to try to kill yourself after you were discharged from the (ED / hospital), during the time the center was following up with you?
    • Yes
    • No    If “No,” skip to #49.

      If “Yes,”  

48a. What had you done to kill yourself?


48b. (Interviewer: please classify actions based on client’s response to #48a)
    • Preparatory behavior (i.e., client obtained method, wrote a note)
    • Aborted attempt (i.e., client stood on bridge ready to jump, held gun to head, held pills in hand, put rope around neck, etc., then changed his/her mind and didn’t go through with it)  
    • Interrupted attempt (i.e., same as aborted attempt, but somebody else or some external event prevented client from acting – client did not change his/her mind) 
    • Attempt in progress (i.e., client shot self, cut self, took pills) 
    • NSSI (i.e., client cut self or otherwise self-harmed with no intent to die)
	 (Interviewer: If NSSI is checked, #48 should be coded “No.”)

      48c. Do you think you were at risk of dying at that time? 

Not at all

A little

Somewhat

A lot

49.  To what extent did the counselor’s contacting you stop you from killing yourself?

A lot

A little

Not at all

It made things worse

	  49a.  Details: What was it about the follow-up contact(s)…?


50. To what extent did the counselor’s contacting you keep you safe? 

A lot

A little

Not at all

It made things worse

	       50a.  Details:  What was it about the follow-up contacts…?



51.  When the counselor(s) contacted you to follow up with you, did you and the counselor(s) identify any warning signs of emotional distress  (including thoughts, feelings or behaviors) that can alert you that you may be at risk of becoming suicidal again in the future?
    • Yes
    • No
    • Do not remember

	If “Yes”,   51a. Has being aware of this been helpful to you?

Very much

Somewhat

A little

Not at all

N/A

52.   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:      52a. Has being aware of this been helpful to you?

Very much

Somewhat

A little

Not at all

N/A

52b. 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:     52c. Has this been helpful to you?

Very much

Somewhat

A little

Not at all

N/A

53.   Did you and the counselor(s) develop a plan for what you could do to keep yourself safe if you are feeling suicidal?
    • Yes
    • No
    • Do not remember

           53a. Comments/clarification by follow-up interviewer and/or client about safety plan: 



54.  During the call(s) with the counselor(s): 

 If Discussed:

54a.  Has this been helpful to you?
Did you and the counselor(s) talk about:
Yes
No
Do not remember
Yes
No
N/A
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?









54b)  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 went to the hospital?


In this next section, we’re going to talk about some informal or social resources that you and the follow-up counselor(s) might have 
discussed.  Just to clarify, these aren't professional resources.  





















55b. Informal/Social Safety Resources identified include: (check all that apply)  
    • Family member(s)    
    • Friend(s)    
    • Other people; Please specify:	
   Social environment(s); Please specify: ___________________________________ 

55c.  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:

56.  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 client 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
         health 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    


  Urgent Care/Emergency Resources 
      
      ASK:  Did the counselor(s) advise you to contact their crisis center or some other crisis
      hotline or center? 
    • Crisis hotline/Crisis center
    • Client advised to use crisis chat/text service
    • Client advised to call center that provided follow-up
    • Client advised to call the Lifeline
    • OTHER crisis hotline or center


ASK:  And did you and the counselor(s) talk about using any urgent care or emergency resources, such as the ER, 911, or Mobile Crisis?
    •  Emergency Resources not including hotlines
  Emergency Room/Urgent Care facility
  EMS
  Mobile Crisis
  911
  Police
  Other: _________________________

If Yes, when did the counselor suggest you should use… (ask for each emergency service endorsed)


Immediately
Next Day
If suicidal in the future
Emergency Room/Urgent Care facility



EMS



Mobile Crisis



911



Police



Other (describe: _________________



		
		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 client received no formal resource referrals not already used/currently in use by client (i.e., no NEW or PRIOR professional resources, and no emergency resources other than the current hotline/center), skip to question #59.     

If client 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 #57.  

These questions are about the referrals you and the counselor(s) discussed. 

You mentioned that you and the counselor(s) discussed ___________ (for NEW referrals). 

57.   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)

58. 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)






Referral Follow-through

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 since discussed with counselor?


Discussed*
With counselor(s)


Used
since


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

*The computer program automatically codes the Resource Type “discussed” as “yes”, when it is 
  endorsed as “yes” by the client earlier in the interview. 

Barriers to Service Use
60. Interviewer:  Did the counselor discuss resources with the client that s/he was not able to follow through on, or decided not to use? 
    • Yes	     If “yes, go to question #60a
    • No 		If “no”, go to question #61 

60a. 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”).


 Licensed Mental Health Professionals  
    • Financial Barriers (e.g., too expensive, no health insurance) 
Details: ____________________________________________________________

    • Structural Barriers (e.g., long waiting list, 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: ____________________________________________________________

    • Personal Barriers (e.g., lost the number, too busy, personal circumstances made it too difficult)
Details: ____________________________________________________________

    • Any other types of barriers:
Details: ____________________________________________________________

 Other counseling services/ support groups 
    • Financial Barriers (e.g., too expensive, no health insurance) 
Details: ____________________________________________________________

    • Structural Barriers (e.g., long waiting list, 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: ____________________________________________________________

    • Personal Barriers (e.g., lost the number, too busy, personal circumstances made it too difficult)
Details: ____________________________________________________________

    • Any other types of barriers:
Details: ____________________________________________________________

 Other Professional Resource(s)
    • Financial Barriers (e.g., too expensive, no health insurance) 
Details: ____________________________________________________________

    • Structural Barriers (e.g., long waiting list, 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: ____________________________________________________________

    • Personal Barriers (e.g., lost the number, too busy, personal circumstances made it too difficult)
Details: ____________________________________________________________

    • Any other types of barriers:
Details: ____________________________________________________________

SERVICE USE SINCE ED/HOSPITAL DISCHARGE

The next questions are about any services you may have used, whether or not you discussed 
them with the counselor(s).  Since you were discharged from the (ED / Hospital) on (date), have 
you used or made contact with any of the following services or resources, or are you in ongoing treatment?

(Interviewer: code all service types endorsed in #59a [referral follow-through], as well as any other service 
types the client has used since the crisis contact.  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 contact, skip to #86.)

61.    Hotline Services    Specify:____________________
    • Completed contact as follows: (check all that apply)
    • Called hotline/center that provided follow-up
    • Called different hotline / phone counseling at different center       If “yes”, to #62
    • Used online crisis chat service
    • Used crisis text service

    • Called/attempted contact but not yet able to speak to anyone   –   If yes, go to #63.

    • Called/attempted contact & found out that I can't, or         If yes, go to #64.
			don't want to use this service  

62.   How much have you benefited from this service in your opinion?
    • Had a negative impact
    • No benefit/impact
    • Some benefit
    • A great benefit

63. 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

64.   Other Emergency Services   Specify:____________________
    • Completed contact as follows: (check all that apply)
    • Presented at Emergency Room/Urgent Care facility          
    • Called 911
    • Safety check by Sherriff/Police 									    If yes, go to #65.
    • Transported by EMS/Police
    • Evaluated by Mobile Crisis 
    • Transported by Mobile Crisis

    • Called/presented & found out that I can't, or          If yes, go to #68.
	   don't want to use this service                         


65. How much have you benefited from this service in your opinion?
    • Had a negative impact
    • No benefit/impact
    • Some benefit
    • A great benefit

66. How well do you think this service matches your needs?
    • Not well
    • Somewhat well
    • Very well

67. Who will pay or has already paid for this service? 
      (Code all that apply.)
    • Your insurance 
    • You or your family (does not include co-pay)
    • Any other sources    If “Yes,” Specify:____________________
    • Services free

68.  Mental Health Services     Specify:____________________  
    • Kept more than one appointment            
    • Completed one appointment 				  If yes, go to #69.

    • Treatment is ongoing, but no appointments kept since crisis contact  —  If yes, code “Yes” to #69 and go to #70.

    • Completed intake (with new provider)       
    • Have an appointment set up (with new provider) 
    • Called/Spoke with someone waiting for appoint – willing to wait     	If yes, go to #71.
    • Called/Call not yet returned/Not yet able to speak with anyone

    • Called & found out that I can’t, or don’t want to use this service  —  If “Yes,” go to #74.

69.  Are you still in treatment?     Yes     No

70.  How much have you benefited from this service in your opinion?
    •  Had a negative impact
    •  No benefit/impact
    •  Some benefit
    •  A great benefit

71.  How well do you think this service matches your needs?
    • Not well
    • Somewhat well
    • Very well

72.  Did receiving follow-up from the crisis center influence your use of this service?
    • Yes			
		If  yes, in what way?
    •   Counselor provided me with this referral/told me about this resource
    •   Counselor encouraged me to seek treatment or to remain in treatment
    •   Other: _____________________________________________
    • No
		If no, details:
    •   Already using service prior to follow-up
    •   Client found service on his/her own, or through some other referral source

73.  Who will pay or has already paid for this service? (Code all that apply.)
    • Your insurance (group plan through employer or other organization)
    • Private insurance (individual or family plan)
    • You or your family (not including co-pay)
    • Any other sources    If “Yes,” Specify:____________________
    • Services free

74.  Other counseling/support services      Specify:____________________  
    • Kept more than one appointment / attended 
more than one session									       			      If yes, go to #75.
    • Completed one appointment / attended one session 

    • Participation is ongoing, but no appointments kept/sessions		If yes, code “Yes” to #75
attended since crisis contact													and  go to #76.

    •  Completed intake (with new service)                                                                           
    •  Have appointment set up (with new service)                                                              
    • Called/Spoke with someone/Waiting for call back (willing to wait)         If yes, go to #77. 
    • Called/Call not yet returned/Not yet able to speak with anyone

    • Called & found out that I can’t, or don’t want to use this service  —  If “Yes,” go to #80.

75. Are you still in treatment / still participating?     Yes     No

76. How much have you benefited from this service in your opinion?
    •  Had a negative impact
    •  No benefit/impact
    •  Some benefit
    •  A great benefit

77. How well do you think this service matches your needs?
    •  Not well
    •  Somewhat well
    •  Very well

78.  Did receiving follow-up from the crisis center influence your use of this service?
    • Yes
		 If  yes, in what way?
    •   Counselor provided me with this referral/told me about this resource
    •   Counselor encouraged me to seek treatment or to remain in treatment
    •   Other: _____________________________________________
    • No
		 If no, details:
    •   Already using service prior to follow-up
    •   Client found service on his/her own, or through some other referral source

79. Who will pay or has already paid for this service? (Code all that apply)
    •  Your insurance
    •  You or your family (does not include co-pay)
    •  Any other sources    If “Yes,” Specify:_______________________
    •  Services free

80.   Other Formal/Professional Resource    (Please specify: _____________________)
    • Kept more than one appointment                                      
    • Completed one appointment/attended one session		    If yes, go to #81.

    • Treatment is ongoing, but no appointments kept since crisis contact   — If yes, code “Yes” to #81, and go to #82.

    • Completed intake (with new provider)  
    • Have an appointment set up (with new provider)   
    • Called/Spoke with someone/Waiting for call back (willing to wait)        If yes, go to #83
    • Called/Call not yet returned/Not yet able to speak with anyone

    • Called & found out that I can’t, or don’t want to use this service  —  If “Yes,” go to #86.

81. Are you still in treatment?     Yes     No
82. How much have you benefited from this service in your opinion?
    •  Had a negative impact
    •  No benefit/impact
    •  Some benefit
    •  A great benefit

83. How well do you think this service matches your needs?
    •  Not well
    •  Somewhat well
    •  Very well

84.  Did receiving follow-up from the crisis center influence your use of this service?
    • Yes
		 If  yes, in what way?
    •   Counselor provided me with this referral/told me about this resource
    •   Counselor encouraged me to seek treatment or to remain in treatment
    •   Other: _____________________________________________
    • No
		 If no, details:
    •   Already using service prior to follow-up
    •   Client found service on his/her own, or through some other referral source

85. Who will pay or has already paid for this service? (Code all that apply.)
    •  Your insurance
    •  You or your family (does not include co-pay)
    •  Any other sources    If “Yes,” Specify:____________________
    •  Services free


Center for Epidemiologic Studies Depression Scale (CES-D), NIMH

86. 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”.






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 contacted you for follow-up.  Just to let you know, these are mostly yes or no questions.

87. Since the last time you spoke with a follow-up counselor, have you had any thoughts about killing yourself? 
    • Yes
    • No     

88.  Right now, are you having any thoughts about killing yourself?  
    • Yes
    • No (If “No,” go to #89). 

        If “Yes,”
        88a. How much of each day have you been thinking about suicide?  
    • Fleeting thoughts/Once in a while
    • Persistent thoughts/A lot of the time

       88b. Have you been able to control your thoughts about suicide? 
    • Yes
    • No     

89.  Since the last time you spoke with a follow-up counselor, have you had any plans to kill yourself?
 Yes  
 No 

90.  Right now, do you have any specific plans to kill yourself? 
 Yes*   If “Yes,” continue to Question 90a.
 No      If “No,” go to question 94. 
 
90a. Do you have a method in mind?
    • Yes  go to 90b
    • No		go to 90c
Details: ____________________________________

	If yes:
	90b. Is this means available to you?
		 Not available/Has not been obtained
		 Obtained/Close by, but not immediately available
		 Immediately available/On hand
    • N/A

90c. Do you have a place in mind?
    • Yes
    • No	
Details: ____________________________________

90d. Do you have a time in mind?
    • Yes	go to 90e
    • No		go to 91

	If yes:
	90e.   When are you planning to do it? 
    • Immediately/Within a few hours*
    • Within 48 hours
    • Within a week
    • Specific future date (more than a week away)
    • When things get bad enough 


       91. Are you alone now?  
       Yes
       No      If No, go to #92

        91a. Is anyone nearby?
       Yes 
       No 

92. Have you been drinking or taking (illicit) drugs today? 
 Yes
 No     If “No”, go to #93

If Yes:  92a. How much/what kind? ___________________________________________

If they haven’t already mentioned firearms as a part of their plan, ask; if already mentioned, code without asking:
93. Are there any firearms available where you are now? 
 Yes 
 No 

94. Have you done anything to prepare for killing yourself (e.g., obtaining means, writing a note) since your last contact with a follow-up counselor?
    • Yes
    • No	
Details: ____________________________________

95. Have you done anything to try to kill yourself since your last contact with a follow-up counselor? 
 Yes*   If “Yes,” continue to #95a. 
 No      If “No,” go to #98. 
 


          If “Yes”: 
          95a. What did you do? 


        95b. (Interviewer: please classify actions based on client’s response to #95a.)
    • Preparatory behavior (i.e., client obtained method, wrote a note)
    • Aborted attempt (i.e., client stood on bridge ready to jump, held gun to head, held pills in hand, put rope around neck, etc., then changed his/her mind and didn’t go through with it)  
    • Interrupted attempt (i.e., same as aborted attempt, but somebody else or some external event prevented client from acting – client did not change his/her mind) 
    • Attempt in progress (i.e., client shot self, cut self, took pills) 
    • NSSI (i.e., client cut self or otherwise self-harmed with no intent to die)
	 (Interviewer: If NSSI is checked, #95 should be coded “No.”)

        95c. Do you think you were at risk of dying at that time?  

Not at all

A little

Somewhat

A lot

        96. 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)   

97. 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

97a.  For the suicide attempt you made after your last follow-up contact from the center, did you receive mental health treatment from the ER, a hospital, a mental health provider, an in-or outpatient facility, a caseworker, or any other resource? 
 Yes
 No*



98. Right now, when (if) 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

99. 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

100. Right now, how likely are you to try to kill yourself?
      On a scale of 1 to 5, where 1 is “not at all likely,” 3 is “somewhat likely,” and 5 is “extremely likely”: 

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

101.  Thinking back about how you were feeling at the time you went to the hospital on
          (date), and how you are feeling now, would you say you’re....(interviewer: read all choices)
   A lot worse
   A little worse
   About the same
   A little bit better
   A lot better



Note:  The information needed in order to send the money order to the client 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 client (suggested wording for that summarization is 
detailed in the following page).  

The information needed for sending the money order to the client is obtained.


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



Mailing Address:

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


The client is thanked for his/her participation.
If required, interviewer initiates conference call with client and crisis counselor.

Conference Call Record:
Conference call required? (See summary on next page to see if client meets criteria)
            ▪ Yes    
            ▪ No 	

                      If “Yes”:	Did client agree to conference call?      Yes      No 

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

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



MANDATORY CONFERENCE CALL:
If client meets the criteria for the mandatory conference call, you must initiate a conference call with the 
client and the crisis center that has been conducting the follow-up calls with the client.  

If you encounter a busy signal, you can work with the client a few minutes more and then try again,
or conference call with the client to 1-800-273-TALK(8255) or 1-800-SUICIDE.


Criteria for Mandatory Conference Call

(1) The client has made a suicide attempt since the most recent follow-up contact  from the center, 
and did not receive any treatment after the attempt.  If the client has made more than one attempt 
since the most recent follow-up contact, then this criterion relates to the most recent attempt. 

(2) The client 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 Client:
“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 center 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 center.  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 client agrees to the conference call, keep the client 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 center's telephone number.  While I'm doing this, you won't hear anything, but I'm still connected with you.  After the center 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 client agrees to speaking with the center, but cannot or does not want to do so via a conference 
call, then call the crisis center, give the center your name and telephone number, the client's name 
and telephone number, and details about what the client endorsed during the assessment. 

IF THE CLIENT REPORTS PROBLEMS BUT DOES NOT MEET THE CRITERIA for a mandatory 
conference call, but might benefit from a crisis intervention call with the crisis center, then discuss this 
with the client.  

Suggested Wording to Use With the Client:
“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 the crisis center to speak with a counselor to help you with the things you have been going through. You could also call the Lifeline at 1-800-273-TALK(8255).”  

IF THE CLIENT DOES NOT MEET CRITERIA FOR A CONFERENCE CALL AND DOES NOT 
REPORT PROBLEMS:

Suggested Wording to Use With the Client:
“From what you have told me today, you seem to be doing well since you were discharged from the hospital.  
However, if you ever want some help with a problem in the future, feel free to call the crisis center or the Lifeline at 1-800-273-TALK(8255).”