Florida School Toolkit for K-12 Educators to Prevent Suicide

Assessed Level of Risk: Low:_____ Medium:_____ High:_____ Student: Grade: Counselor/Suicide Response Designee: School: Administrator: Date: Actions Taken Date Action Members Present Notes Student conference Principal and key personnel notified Parent notification Parent conference Student safety plan Parent/Emergency notification signed Release of information section signed Mental health provider referral Other community referral Follow-up Documentation Student: Risk Assessment Completed by: Student's Counselor Notified: Yes/No Parent: Community Referral(s)/Resources: ____ Check to confirm copies provided to counselor and administrator. Tool 19 Documentation Form for Notification Steps and Community Referral(s) 85