Florida School Toolkit for K-12 Educators to Prevent Suicide

School: Date: Student: As the parent/guardian of the student, whose name is ________________________________, I have authority to make decisions on behalf of my child and have the authority to sign this document. I acknowledge that I have been advised by school staff member __________________________ on _________________________ that my child has expressed suicidal ideation and may be at risk of suicide. I have been advised that a common method of suicide is a gun and I have been asked to secure all guns in my home, and ensure that other common means of sucide, such as pills and ropes, are inaccessible to my child. I understand that removal of all lethal means is an essential suicide prevention strategy. I understand that I have been advised to take my child immediately to the appropriate medical and/or mental health providers for evaluation and treatment. I agree to release information to __________________________(name of school and/or staff member) regarding any evaluations and/or treatment recommendations from the mental health provider that will prepare the school to support my child’s reentry into the academic setting. ______________________(name of staff member) will follow up with me and my child within one week from the date of this letter, as well as other times that the staff member determines. I understand that any referral information provided to me that identifies medical, mental health, or related health providers is meant for my consideration only and not a requirement that I use these providers. I am free to select other providers of my choice. The school/district is not responsible for evaluation expenses for any service providers. Parent/Guardian Signature: Date: Print Name: Parent/Guardian Address and Phone Number: Staff Member Signature: Date: Witness Signature (If parent refuses to sign): Date: ____ Check to confirm copies provided to the parent, counselor, and administrator. TOOL 18 Parent/Emergency Notification Form for Student at Risk of Suicide Florida S.T.E.P.S.