Professional referrals

Suicide Prevention, Education and Counselling (SPEAC) Form

Request for Referring Professionals

This form is used by professionals to refer young people who have made or are at risk of a suicide attempt.

* required fields

Referring Professional

First name

Last name

Community agency or institution

Phone number

Preferred time to call

Email address

Person Being Referred

First name

Last name

Date of Birth

Date of Birth: Year

Date of Birth: Month

Date of Birth: Day

School

Community of residence

Does the young person have a safety plan in place?

Yes

No

Please describe the safety plan

C-SSCS Suicidal Ideation Severity

1) Wish to be dead

Have you wished you were dead or wished you could go to sleep and not wake up?

Yes

No

Please Provide As Much Details Possible

Youth endorses thoughts about a wish to be dead or not alive anymore, or wish to fall asleep and not wake up.

2) Current suicidal thoughts

Have you actually had any thoughts of killing yourself?

Yes

No

Please Provide As Much Details Possible

Youth has general thoughts of ending one’s life/die by suicide without any specific method, intent or plan (Ex. I’ve thought about killing myself…)

3) Suicidal thoughts w/ Method (w/no specific Plan or Intent or act)

Have you been thinking about how you might kill yourself?

Yes

No

Please Provide As Much Details Possible

Youth has thought of at least one method with not a specific plan, intent, or act (Ex. I thought about taking an overdose but no specific plan as to when, where, or how).

4) Suicidal Intent without Specific Plan

Have you had these thoughts and had some intention of acting on them?

Yes

No

Please Provide As Much Details Possible

Youth has active suicidal thoughts with some intent to act on thoughts but no specific plan

5) Intent with Plan

Have you started to work out or worked out the details of how to kill yourself?

Yes

No

Did you intend to carry out this plan?

Yes

No

Please Provide As Much Details Possible

Youth has thoughts of killing oneself with details of plan fully or partially worked out and subject has some intent to carry it out (Ex. date, time, location).

6) C-SSRS Suicidal Behavior

Have you ever done anything, started to do anything, or prepared to do anything to end your life?

Yes

No

Please Provide As Much Details Possible

Examples: 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 or it was grabbed from your hand, went to the roof but didn’t jump; or actually took pills, tried to shoot yourself, cut yourself, tried to hang yourself, etc.

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Professional referrals

Suicide Prevention, Education and Counselling (SPEAC) Form

Request for Referring Professionals

* required fields

1) Wish to be dead

Youth endorses thoughts about a wish to be dead or not alive anymore, or wish to fall asleep and not wake up.

2) Current suicidal thoughts

Youth has general thoughts of ending one’s life/die by suicide without any specific method, intent or plan (Ex. I’ve thought about killing myself…)

3) Suicidal thoughts w/ Method (w/no specific Plan or Intent or act)

Youth has thought of at least one method with not a specific plan, intent, or act (Ex. I thought about taking an overdose but no specific plan as to when, where, or how).

4) Suicidal Intent without Specific Plan

Youth has active suicidal thoughts with some intent to act on thoughts but no specific plan

5) Intent with Plan

Youth has thoughts of killing oneself with details of plan fully or partially worked out and subject has some intent to carry it out (Ex. date, time, location).

6) C-SSRS Suicidal Behavior

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