District-Wide Safe Schools and Crisis Plan - Blytheville Public Schools

H.7. SUICIDE PREVENTION ASSESSMENT/RESPONSE (SPAR) FORM
Students' Name _________________________DOB_________ Sex: M:____ F:____
School ____________________________Grade_____Teacher__________________
Parent's Names________________________________________________________
Address________________________________________________________________
Phone:(Hm)__________________ (Wk)_____________________
Person Completing (SPAR) __________________________ Date________________
Other Crisis Team Members:
This form can be used to plan, conduct, and record a suicide prevention assessment interview with a student. The
crisis team member can use this form as a guide in making decisions regarding the information that should be
gathered. This form is also designed to serve as an aid in monitoring any follow up of interventions initiated.
When incident occurred:________________________________________________________
Who referred:________________________________________________________________
Content of referral
incident:_____________________________________________________________
___________________________________________________________________________
Any history of counseling/mental health care? NO____ YES____
In therapy now? If yes; Who/Where_______________________________________________
___________________________________________________________________________
Category of present self-destructive behavior (check any that apply):
_____Serious attempt - doing something that she/he believes will
cause death, having the conscious intent to die.
_____Mild attempt - behaving self-destructively in a way that the
student accurately perceives would not be a serious threat to life.
_____Suicidal threat - saying or doing something that indicates a
self-destructive desire.
_____Suicidal ideation - thinking about killing oneself.
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