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.

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Referring Professional
Person Being Referred
Does the young person have a safety plan in place?
C-SSCS Suicidal Ideation Severity
1) Wish to be dead
Subject endorses thoughts about a wish to be dead or not alive anymore, or wish to fall asleep and not wake up.


Have you wished you were dead or wished you could go to sleep and not wake up?
2) Current suicidal thoughts
General non-specific thoughts of wanting to end one’s life/die by suicide (e.g., “I’ve thought about killing myself”) without thoughts of ways to kill oneself/associated methods, intent, or plan during the assessment period.
Have you actually had any thoughts of killing yourself?
3) Suicidal thoughts w/ Method (w/no specific Plan or Intent or act)
Subject endorses thoughts of suicide and has thought of at least one method during the assessment period. This is different than a specific plan with time, place or method details worked out (e.g., thought of method to kill self but not a specific plan).  Includes person who would say, “I thought about taking an overdose but I never made a specific plan as to when, where or how I would actually do it…and I would never go through with it.”


Have you been thinking about how you might kill yourself?
4) Suicidal Intent without Specific Plan
Active suicidal thoughts of killing oneself and subject reports having some intent to act on such thoughts, as opposed to “I have the thoughts but I definitely will not do anything about them.”
Have you had these thoughts and had some intention of acting on them?
5) Intent with Plan
Thoughts of killing oneself with details of plan fully or partially worked out and subject has some intent to carry it out.


Have you started to work out or worked out the details of how to kill yourself?
Did you intend to carry out this plan?
6) C-SSRS Suicidal Behavior
Have you ever done anything, started to do anything, or prepared to do anything to end your life?

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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