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.