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

First name

Last name

Phone number

Preferred time to call

Email address

Preferred method of contact

Person Being Referred

Name of youth being referred

Date of Birth

School

Community of residence

Is there a safety plan in place?

Yes

No

If you are in crisis, please call 911 or crisis lines (604.951.8855 or 9.8.8) as someone will be available to help you.

Please describe the safety plan

If you are in crisis, please call 911 or crisis lines (604.951.8855 or 9.8.8) as someone will be available to help you.

C-SSRS Self-Report - Recent

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

Yes

No

Have you actually had any thoughts of killing yourself?

Yes

No

Have you thought about how you might do this?

(For example, “I thought about taking an overdose but I never worked out the details about when, where, and how I would do that and I would never act on these thoughts.”)

Yes

No

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)?

(For example, “I had the thought of killing myself by taking an overdose and I’m not sure whether I would do it or not.”)

Yes

No

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?

(For example, “I am planning to take 3 bottles of my sleep medication this Saturday when no one is around to stop me.”)

Yes

No

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.)

Yes

No

Are you or your child/youth accessing or working with any other mental health professionals?

Yes

No

Please provide as much detail as possible.

FRASER HEALTH CRISIS LINE

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Self or parent/caregiver referrals

Suicide Prevention, Education and Counselling (SPEAC) Form

Request for Self or Parent/Caregiver Referral

* required fields

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