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(for Primary Counselor) Trunk 639-______
CALLER ________________________ M/F __________ AGE _____

ADDRESS __________________________________________________

_______________________________________PHONE ______________

COUNSELOR __________________________ DATE _______________

PHONE NAME _________________________ TIME _______________ [ ]AM [ ]PM

MINUTES USED _____________

****NOTE: If a Suicide is IN PROGRESS or IMMINENT get another counselor’s assistance to Trace the call
establish rapport
assess suicide risk reflecting caller’s feelings REINFORCE REASONS TO LIVE
Graphing Degree of Risk: Diffuse Crisis with Empathy: Positives: Negatives:
Suicidal thoughts __I__I__I__I__I__I__I__ [ ] Abandoned [ ] Lonely Relations: [ ] Spouse/Significant Other [ ]
Low Med High [ ] Angry [ ] Mistrustful [ ] Children [ ]
Suicidal intent __I__I__I__I__I__I__I__ [ ] Anxious [ ] Obsessed [ ] Parents [ ]
Low Med High [ ] Ashamed [ ] Overwhelmed [ ] Friends [ ]
Plan for Suicide/Means __I__I__I__I__I__I__I__ [ ] Bored [ ] Physical Pain [ ] Siblings [ ]
Low Med High [ ] Confused [ ] Rejected [ ] Pets [ ]
Means (Access to) __I__I__I__I__I__I__I__ [ ] Depressed [ ] Scared/Fear Religion: [ ] Church [ ]
Low Med High [ ] Discouraged [ ] Stressed [ ] Beliefs about suicide [ ]
Time and Place __I__I__I__I__I__I__I__ [ ] Grief/loss [ ] Stuck Health: [ ] Mental health [ ]
Low Med High [ ] Guilty [ ] Tired [ ] Physical health [ ]
Previous Attempts __I__I__I__I__I__I__I__ [ ] Hopeless [ ] Other _______ [ ] Addictions [ ]
Low Med High [ ] Sexual [ ]
Family/friend suicided __I__I__I__I__I__I__I__ Job: [ ] Finances [ ]
Low Med High [ ] Employment [ ]

TAKE ACTION
Set contract: Who did caller commit to? ______________________________When? _____________

Did you attempt to have the call TRACED? Y / N Assistant Counselor’s Name: ___________________

What specifically did the caller need help with? _____________________________________________

____________________________________________________________________________________

______________________________________________(Continue on back)

How was caller helped? _________________________________________________________________

What specific Referral(s) did you make? ___________________________________________________
How do you feel now? SPECIAL HANDLING:
[ ] Urgent message from caller [ ] Frequent Caller
[ ] Send materials ____________________________
[ ] Counselor has question or concerns (Explain on back)
suicide 1/25/97
SUICIDE ASSISTANT CONTACT SHEET
(for Primary Counselor)

CALLER ________________________ M/F __________ AGE _____

ADDRESS ____________________________________________________________________

PHONE __________________ COUNSELOR __________________________ DATE _______________

PHONE NAME _________________________ TIME _______________ [ ]AM [ ]PM

MINUTES USED _____________

Turn your PHONE OFF. Turn the intervening counselor’s SPEAKER PHONE ON

If a SUICIDE is in progress or imminent, you need to TRACE THE CALL. (Use the standard Assistant Instruction Sheet, (hot pink in plastic)

assess suicide risk take action:
Graphing Degree of Risk:
Suicidal thoughts __I__I__I__I__I__I__I__ Write down the 7 digit number of primary counselor’s phone, displayed in the window (639-_____)
Low Med High Write down the 7 digit number written on your phone under the handset (971-_____)
Suicidal intent __I__I__I__I__I__I__I__ Contact the Emergency Traceback Officer by pressing button labeled EMERGENCY TRACEBACK.
Low Med High If the call does not go through, then dial 9-100-421-2568
Plan for Suicide/Means __I__I__I__I__I__I__I__ Give the Tracing Officer your real name and tell them you are calling from New Hope Crisis Hotline.
Low Med High Provide the Tracing Officer with trunk number first from the intervening counselors phone.
Means (Access to) __I__I__I__I__I__I__I__ Now provide them the number written on your phone (under handset) 971-_______
Low Med High Name of Tracing Officer_________________________
Time and Place __I__I__I__I__I__I__I__ Was the trace successfully completed? ____ How long did it take? (If known) ________
Low Med High Was the police department in the city where the caller is contacted?
Previous Attempts __I__I__I__I__I__I__I__
Low Med High
Family/friend suicided __I__I__I__I__I__I__I__
Low Med High

COMMENTS _________________________________________________________________________

_______________________________________________________________________((Continue on back)

How do you feel now? SPECIAL HANDLING:
[ ] Urgent message from caller [ ] Frequent Caller

[ ] Send materials ____________________________
[ ] Counselor has question or concerns (Explain on back)
SUICIDE 1/25/97