SMH Screener Form — Wayne STEM Academy

✎ Step 1 — Student & Referral Information

⚠ TAKE SUICIDAL BEHAVIOR SERIOUSLY EVERY TIME No student expressing suicidal thoughts should be sent home alone or left alone during the screening process. If imminent danger exists — call 911 immediately.

Student Name *

Grade *

Date of Birth

Date of Screening *

Time

Risk Assessor(s) *

Parent / Guardian Name

Parent / Guardian Contact

Referral Source (who referred the student?)

Reason for Assessment — describe specific behaviors or comments heard or reported *

▼ Step 2 — Suicide Ideation (Questions 1–2)

Complete in a private interview. Convey nonjudgmental support. Direct supervision is required throughout.

1

Wish to be Dead

Person endorses thoughts about a wish to be dead or not alive anymore, or wishes to fall asleep and not wake up.

Have you wished you were dead or wished you could go to sleep and not wake up?

Yes No

2

Suicidal Thoughts

General non-specific thoughts of wanting to end one's life/commit suicide, without general thoughts of ways to kill oneself, associated methods, intent, or plan.

Have you actually had any thoughts of killing yourself?

Yes No

▼ Questions 3–6 (Complete if YES to Q2)

⚠ Q2 = Yes Complete all of questions 3–6.

Past month

3

Suicidal Thoughts with Method (without Specific Plan or Intent to Act)

Person has thought of at least one method. "I thought about taking an overdose but never made a specific plan as to when, where, or how… and I would never go through with it."

Have you been thinking about how you might kill yourself?

Yes No

4

Suicidal Intent (without Specific Plan)

Active suicidal thoughts and some intent to act, as opposed to "I have the thoughts but I definitely will not do anything about them."

Have you had these thoughts and had some intention of acting on them?

Yes No

5

Suicide Intent with Specific Plan

Thoughts of killing oneself with plan details fully or partially worked out and some intent to carry it out.

Have you started to work out the details of how to kill yourself? Do you intend to carry out this plan?

Yes No

6

Suicidal Behavior

Have you ever done anything, started to do anything, or prepared to do anything to end your life? (e.g., collected pills, obtained a gun, wrote a suicide note, took pills, cut yourself, etc.)

If YES — how long ago? Over a year ago? Between 3 months and a year? Within the last 3 months?

Yes No

Explain:

▼ Questions 7–15 — Changes in Mood, Behavior & Stressors

Changes in Mood / Behavior

7

Mood / Behavior

In the past year, felt so sad he/she stopped doing regular activities?

Yes No ?

Specify:

8

Mood / Behavior

Demonstrated abrupt changes in behaviors?

(e.g., eating, sleeping, decline in school performance, quit club/sports, gave away personal possessions)

Yes No ?

9

Mood / Behavior

Demonstrated recent, dramatic changes in mood?

(e.g., change from depression to contentment, happiness to depression, etc.)

Yes No ?

10

Mood / Behavior

Experiencing emotional pain that feels unbearable?

(e.g., desperate for relief from pain, willing to do anything to stop the pain)

Yes No ?

Stressors

11

Stressors

Had a personal connection to, or identified with, someone who committed suicide?

Yes No ?

Who:

12

Stressors

Had a recent death of a loved one or significant loss?

(e.g., breakup of a romantic relationship)

Yes No ?

13a

Stressors

Experienced a new trauma or stressor?

Yes No ?

Specify:

13b

Stressors

Experienced a chronic/ongoing stressor?

(feelings of loneliness, life stress)

Yes No ?

Specify:

14

Stressors

Experienced a significant health concern? (self or other)

Yes No ?

Specify:

15

Stressors

Experienced abuse or victimization?

Yes No ?

Specify:

▼ Questions 16–28 — Mental Health, Protective Factors & Personal

Mental Illness & Substance Use

16

Mental Illness

Has a history of mental illness?

(e.g., depression, conduct disorder, or anxiety)

Yes No ?

Specify:

17

Mental Illness

Currently in counseling?

If student is in counseling, the therapist must be informed of ideations.

Yes No ?

With whom:

18

Substance Use

Has a history of substance abuse?

Yes No ?

Specify:

Protective Factors

19

Protective

Has a support system of family, friends, or pets?

Yes No ?

Specify:

20

Protective

Has a sense of purpose in his/her life? (commitments, plans, etc.)

Yes No ?

Specify:

21

Protective

Readily names plans for the future / indicates a reason to live?

Yes No ?

Specify:

22

Protective

Who would the individual want to stop him/her if he/she had a plan?

Specify:

23

Protective

Who would be hurt if the plan was carried out? (family, friends, pet, etc.)

Specify:

24

Protective

What happens to people who die? (religion/spiritual beliefs)

Response:

25

Protective

What happens to people who die by suicide? (religion/spiritual beliefs)

Response:

Personal Factors

26

Personal

Engages in risky behavior?

Yes No ?

Specify:

27

Personal

Impulsive acting-out?

(quickly escalates conflict, flees/runs away, etc.)

Yes No ?

Specify:

▲ Step 3 — Risk Level Determination

The system suggests a risk level based on answers. The risk assessor must make the final determination in consultation with WSA Leadership Team.

Completing assessment to calculate suggested risk level...

Final Risk Level Determination (assessor confirms)

Additional Notes / Clinical Observations

WSA Leadership Team — Crisis Consultation
Dean of Academics (Crisis Lead): Courtney Smith — courtney.smith@waynestem.org
Dean of Students: Amber Daniels — amber.daniels@waynestem.org
Director of Ops & Leadership: Josh Preskitt — josh.preskitt@waynestem.org
Enrollment & SIS Coordinator: Sharon Bass — sharon.bass@waynestem.org

☑ Step 4 — Required Actions

Parent contacted — Name: Date: Time:

Release student only to (if mod/high):

✍ Coping Plan

Step 1: Warning Signs / Triggers

Step 2: "By Myself" Coping Tools — things I can do to take my mind off my problems

Step 3: At School — Who

Step 3: At School — Where

Step 3: At Home — Who

Step 3: At Home — Where

Step 4: Adults who care about me (do NOT list student names)

Step 5: Reasons to Live

Step 6: Safety Resources If You Need Help Right Away

911Police / Emergency Medical Care

1-888-302-0738Trillium Mobile Crisis — Wayne County

1-866-241-7245Wayne County Mobile Crisis

988Suicide & Crisis Lifeline — call or text

Text 741741Crisis Text Line — text HOME to 741741

📋 Parent / Guardian Notice

Parent must be notified regardless of risk level. Obtain signature or document phone notification with two staff signatures.

Parent Notification Method

Second Staff Witness (if phone)

Parent/Guardian Agreed To

Exceptions / Notes

Emergency Resources Shared with Family

911Police / Emergency

1-888-302-0738Trillium Mobile Crisis

988988 Suicide & Crisis Lifeline

Text 741741Crisis Text Line

📋 Support Plan

Complete for moderate and high risk. Review after 6–8 weeks.

Daily Check-Ins With

Weekly Check-Ins With

Designated Safe Place at School

Person Responsible

School Support Notes (supervision settings, schedule changes, etc.)

Family / Home Options (dangerous objects removed, supervision, mental health services)

Mental Health Referral / Provider

Plan Review Date (6–8 weeks)

Reviewing Staff Member

Additional Comments

✓ Review & Submit

💾 Save to Google Sheets & Email Notification

On submission: logs to the WSA Google Sheet for leadership tracking and emails a complete formatted record to all recipients below. Recipients can print to PDF directly from their email for the student file.

✉ Email Recipients — Notified on Every Submission

ⓘ Recipients are saved in this browser. Re-enter on any new device.

● Wayne STEM Academy — Suicide Risk Screening Form

Changes in Mood / Behavior

Stressors

Mental Illness & Substance Use

Protective Factors

Personal Factors

Step 6: Safety Resources If You Need Help Right Away

Emergency Resources Shared with Family

💾 Save to Google Sheets & Email Notification