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Self or parent/caregiver referrals

Suicide Prevention, Education and Counselling (SPEAC) Form

Request for Self or Parent/Caregiver Referral

This form is used by young people or their parents/caregivers to access people suicide related support.

* required fields

Referring Person
Person Being Referred
Is there a safety plan in place?
C-SSRS Self-Report - Recent
Have you wished you were dead or wished you could go to sleep and not wake up?
Have you actually had any thoughts of killing yourself?
Have you thought about how you might do this?
Have you had any intention of acting on these thoughts of killing yourself at all (as opposed to having thoughts but being definitely sure that you would not act on them)?
Have you started to work out, or already worked out, the specific details of how to kill yourself and did you actually intend to carry out the details of your plan?
In the past month, have you ever done anything, started to do anything, or prepared to do anything to end your life?
(For example: Collected pills, obtained a gun, gave away valuables, wrote a will or suicide note, took out pills but didn’t swallow any, held a gun but changed your mind about hurting yourself or it was grabbed from your hand, went to the roof to jump but didn’t; or actually took pills, tried to shoot yourself, cut yourself, tried to hang yourself, etc.)
Has this occurred in the past 72 hours?
Will this occur in the next 72 hours?
This has not occurred in the last 72 hours, but has occurred sometime in the last 3 months?
This has not occurred recently, but has occurred within the last year?

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