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
Person Being Referred
Does the young person have a safety plan in place?

We recommend co-creating a safety plan with youth in accordance to your agency protocols.

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?
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?
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?
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?
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?
Did you intend to carry out this 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
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.
Is the referred youth accessing or working with any other mental health professionals?

(counsellor, doctor/psychiatrist, psychologist, social worker, etc.)

Share this content

Translate this Page

Disclaimer