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					     Bering Strait School District




                           Qu ic kTime ™ and a
                             dec omp re ss or
                    are n eed ed to se e th is pi cture.




Protocol For Responding to a Suicide Threat
               Spring 2009
                  Responding to a Suicide Threat
Level I: Minimum threat (rumor or hearsay)
  1. Contact made with and immediate interview conducted by principal, school counselor, or
  school psychologist (please refer to the attached list of questions and risk factors).
  2. Person conducting interview will notify parents/guardians to discuss impressions,
  recommendations and referral source.
  3. Person conducting interview will make contact with Norton Sound, the local VBC, or
  ICWA worker if additional support is needed .
  4. Person conducting interview will document the incident and file report with Principal and
  Coordinator of Program Support.
  Depending upon student response, proceed to steps in levels II or III

Level II: Moderate threat - (Student is thinking of s uicide, but has no plan of
action)
  1. Contact made with principal, school counselor, or school psychologist. Immediate interview
  conducted by principal, school counselor, or school psychologist.
  2. Person conducting interview will notify parents/guardians to discuss impressions,
  recommendations/follow-up and referral source. Secure permission from parent/guardian to share
  information with treatment provider to further assist student.
  3. Person conducting interview will make contact with Norton Sound Behavioral Health, VBC,
  or ICWA worker.
  4. Person conducting interview will document the incident and file report with Principal and
  Coordinator of Program Support.
  Depending upon student response, proceed to steps in level III

Level III: Immediate threat (Individual is in immediate danger of injuring self)
  1. Do not leave person unattended. Notify principal and request support from school counselor,
      school psychologist, VBC, law enforcement.
  2. Request immediate conference with parents/guardians.
  3. Support parents/guardians in decision-making and/or documentation of counseling plan.
  4. Secure parent/guardians permission to share information with treatment provider to further
       assist student (use attached form).
                 Village-Based Counselors
    Village         VBC Name         Contact Information     Norton    Contact
                                                             Sound     Number
                                                           Clinician
 Saint Michael      Alice Fitka        923-2428 Work         Lester    443-3493
                                         2011 home           Keller
  Shishmaref         VACANT              VACANT            Jay David   443-3475
     Elim            VACANT              VACANT              Lester    443-3493
                                                             Keller
   Stebbins          VACANT              VACANT              Marv      443-3312
                                                           Poyourow
Brevig Mission       VACANT              VACANT               Toyo     443-3483
                                                             Suzuki
  Shaktoolik           Teresa          Wk: 955-2409          Marv      443-3312
                  Sockpealuk-Perry     HM: 955-3371        Poyourow
    Koyuk          Wayne Nassuk        Wk: 963-2462          Lester    443-3493
                                       Hm: 963-3958          Keller
   Gambell          Lucy Apatiki       Wk: 985-5443        Jay David   443-3475
   Diomede           VACANT             VACANT             Jay David   443-3475
    Teller          Josie Garnie       Wk: 642-2175           Marv     443-3312
                                       Hm: 642-2030        Poyourow
White Mountain       VACANT             VACANT               Lester    443-3493
                                                             Keller
   Golovin         Duane Lincoln       Wk: 779-2002          Lester    443-3215
                                       Hm: 779-3341          Keller
  Unalakleet       Elvina Turner       Wk: 624-3058          Lester    443-3215
                                       Hm: 624-3571          Keller
    Wales          Ellen Richard       Wk: 664-2177          Lester    443-3215
                                       Hm: 664-3472          Keller
  Savoonga        Rosemary Akeya       Wk: 984-6635           Toyo     443-3483
                                      Hm: None Listed        Suzuki
    Nome                                                    Melissa    443-3202
                                                           Bachmann
                     Youth Suicide Risk Factors
Here’s an Easy-to-Remember Mnemonic:

IS PATH WARM?
I     Ideation
S     Substance Abuse

P        Purposelessness
A        Anxiety
T        Trapped
H        Hopelessness

W        Withdrawal
A        Anger
R        Recklessness
M        Mood Changes

Warning Signs of Acute Risk:

   * Threatening to hurt or kill him or herself, or talking of wanting to hurt or kill
him/herself; and/or,
   * Looking for ways to kill him/herself by seeking access to firearms, available
pills, or other means; and/or,
   * Talking or writing about death, dying or suicide, when these actions are out of
the ordinary.

These might be remembered as expressed or communicated ideation. If observed,
seek help as soon as possible by contacting a mental health professional or calling
1-800-273-TALK (8255) for a referral.

Additional Warning Signs:

    * Increased substance (alcohol or drug) use
    * No reason for living; no sense of purpose in life
    * Anxiety, agitation, unable to sleep or sleeping all the time
    * Feeling trapped - like there’s no way out
    * Hopelessness
    * Withdrawal from friends, family and society
    * Rage, uncontrolled anger, seeking revenge
    * Acting reckless or engaging in risky activities, seemingly without thinking
    * Dramatic mood changes.
If observed, seek help as soon as possible by contacting a mental health
professional or calling 1-800-273-TALK (8255) for a referral.


                           Suicide Risk Assessment
Over the last 2 weeks, how often have      Not at all   Several   More than   Nearly
you been bothered by any of the                         days      half the    every day
following problems?                                               days
1. Little interest or pleasure in doing
things
2. Feeling down, depressed, or
hopeless
3. Trouble falling or staying asleep, or
sleeping too much
4. Feeling tired or having little energy
5. Poor appetite or overeating
6. Feeling bad about yourself—or that
you are a failure or have let yourself
or your family down
7. Trouble concentrating on things,
such as reading the newspaper or
watching television
8. Moving or speaking so slowly that
other people could have noticed. Or
the opposite—being so fidgety or
restless that you have been moving
around a lot more than usual
9. Thoughts that you would be better
off dead, or of hurting yourself in
some way
         AUTHORIZATION FOR USE AND DISCLOSURE OF HEALTH
                         INFORMATION

Patient Name:                                                     Date of Birth:
Patient Address:
Patient Telephone:

I authorize the use/disclosure of health information about the above named patient as
described below.

1. Person(s) or name of facility authorized to disclose the information:
   Norton Sound Health Corporation/Behavioral Health Services


2. Person(s) or class of persons authorized to receive the information:
   Bering Strait School District – send records attention to_____
   PO BOX 225, UNK, AK, 99684

3. Description of health information that may be used/disclosed/received:

   □X Records for the following dates: ALL
   □X Records for the following treatment: ALL
   □ Billing statements for the following dates/treatment:
   □X Other: Allow cons ultation and exchange of verbal information

     I authorize the information listed below to be used, disclosed and/or received:

     □X Mental           X Substance           X Developmental             □ AIDS, HIV,
       health              abuse                  disabilities             ARC
       information         information            information

     Information to be released and how it will be used: educational special education
     placement and planning


4. The information will be used/disclosed for the following purposes:

   □ At the request of the individual
   X Other (specify:) To obtain consult to determine current services and behavioral
   health needs
5. I understand that if the person or entity that receives the health information is not a
   health care provider or health plan covered by federal privacy regulations, the health
   information above may be subject to redisclosure and no longer protected by these
   regulations. The recipient, however, may be prohibited from disclosing substance
   abuse information under the Federal Substance Abuse Confidentiality Requirements.

6. I understand that I may refuse to sign this authorization and that my refusal to sign
   will not affect my ability to obtain treatment or payment or my eligibility for benefits.

7. I understand that I may revoke this authorization in writing at any time by notifying
   the Privacy Official except to the extent that action has been taking in reliance on this
   authorization.


8. Unless revoked, this authorization is limited to the following time period
   commencing:

    Commencing: X Date of authorization                         □ Other (specify):
    Ending (expiration date): ONE YEAR

9. I may inspect or copy any information used/disclosed under this authorization. I have
   received a copy of this authorization.

SIGNATURE: I have read this authorization, and I understand it:


X
Signature of Patient or Legally Designated or Personal Representative                Date



X
Please print name of Legally Designated or Personal Representative (if applicable)



If not signed by Patient, description of authority:


Original in Health Record
Copy of form to patient



X WITNESS________________________________________________________


For Organization’s Use:
Date Received:

□ Fees explained if needed:
□ Verification of Identity and Authority
□ Identification:
□ Information sent by:

PROHIBITION ON DISCLOSURE: THIS INFORMATION HAS BEEN
DISCLOSED TO YOU FROM RECORDS WHOSE CONFIDENITALITY IS
PROTECTED BY FEDERAL LAW, FEDERAL REGULATIONS (42 CFR PART 2)
PROHIBIT YOU FROM MAKING ANY FURTHER DISCLOSURE OF THIS
INFORMATION EXCEPT WITH THE SPECIFIC WRITTEN CONSENT OF THE
PERSON TO WHOM IT PERTAINS. A GENERAL AUTHORIZATION FOR THE
RELEASE OF MEDICAL OR OTHER INFORMATION IF HELD BY ANOTHER
PARTY IS NOT SUFFICIENT FOR THIS PURPOSE.
FEDERAL REGULATIONS STATE THAT ANY PERSON WHO VIOLATES ANY
PROVISION OF THIS LAW SHALL BE FINED NOT MORE THAN $500, IN THE
CASE OF A FIRST OFFENSE AND NOT MORE THAN $5,000 IN THE CASE OF
EACH SUBSEQUENT OFFENSE.

				
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posted:10/30/2010
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