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

 

Have you been thinking about how you might kill yourself?
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.”
4) Suicidal Intent without Specific Plan
Have you had these thoughts and had some intention of acting on them?
 
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?
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.)

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