EIRF-Individual Fo EIRF-Individual Form StateTribal

OMB No. xxxx-xxxx

Expiration Date: Month XX, XXXX

Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.  The OMB control number for this project is 0930-0286.  Public reporting burden for this collection of information is estimated to average 3 hours per respondent, per year, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.  Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to SAMHSA Reports Clearance Officer, 1 Choke Cherry Road, Room 2-1057, Rockville, Maryland, 20857.

Garrett Lee Smith (GLS) National Outcomes Evaluation

State/Tribal Suicide Prevention Program

Directions: The following information should be completed by a professional for youth—ages 10-24—who are identified as at risk by a trained gatekeeper or screening tool as part of your GLS program. This form should be completed for every new identification of suicide risk that is made by a trained gatekeeper or screening tool.

As you complete the form, please note that all entries and descriptions of other should not use acronyms or any local terms; please be sure that you only select other when none of the available response options apply and that your descriptions of other be sufficient for someone who is not familiar with your program or community to interpret.

Early Identification, Referral, and Follow-Up (EIRF) Individual Form

SECTION 1. YOUTH DEMOGRAPHICS

1. Participant ID (Site-assigned)

2. Age in years

3. Gender Select one

Male Female Transgender, female-to-male Other, please specify: __________________________

Transgender, male-to-female Transgender, gender non-conforming Information missing

4. Sexual Orientation Select one

• Heterosexual (that is straight)

• Gay/Lesbian

• Bisexual

• Information Missing

5. Ethnicity Select one

• Hispanic/Latino (complete 4a)

• Non-Hispanic/Latino

• Information Missing

5a. If Hispanic/Latino, please specify background Select all that apply

Mexican, Mexican-American or Chicano Puerto Rican Cuban Dominican

Central American South American Information Missing Other, please specify: ___________________

6. Race Select all that apply

American Indian/Alaskan Native Asian Black Other, please specify: ______________________

Native Hawaiian/Pacific Islander White Information missing

SECTION 2: IDENTIFICATION INFORMATION

7. Date of identification

Month Day Year

8. Zip code where the youth was identified

9. Where was the youth first identified? (e.g. In what location, or setting, was the youth identified?)

Select one

• School or School Based Health Center

• College or University (e.g. campus health center, classroom)

• Social Service Agency (e.g. child welfare, supportive housing)

• Juvenile Justice Agency (e.g. pre-trial services, mental health court)

• Home

• Physical Health Agency (e.g. pediatrician, primary care, hospital)

• Mental Health Setting (e.g. private MH provider, psychiatric hospital, outpatient clinic)

• Community based organization, recreation or after school activity (e.g. Boys & Girls club, faith-based organization, AA, job training programs)

• Emergency Response Unit or Emergency Department

• Digital Medium (e.g. Facebook, text message to a friend)

• Don’t Know

• Other, please specify: ______________________________

8a. How was the youth first identified? (e.g., Was the youth identified by a trained gatekeeper or by a screening tool?) Select one

• Trained gatekeeper

• Screening tool

8b. Was this a tribal setting? Select one

• Yes

• No

10. Who first identified the youth as being at risk for suicide? (e.g., Who first noticed that the youth was in need of assessment, or who conducted the screening that identified the youth?) Select one

• School-based mental health service provider (including college or university providers) (e.g. school counselor, social worker, guidance counselor, nurse)

• Teacher or other non-mental health school staff (including college or university staff) (e.g. principal, sports coach)

• Mental health service provider except school-based providers (e.g. clinician, private counselor)

• Community based organization, recreation, religious or after school program staff

• Child welfare or social service staff

• Probation officer or other juvenile justice staff

• Pediatrician or primary care provider

• Police officer, security guard, or other law enforcement staff

• Emergency Responder or other ER staff

• Family member/foster family member/caregiver

• Peer

• Self (i.e. the youth themselves)

• Don’t Know

• Other, please specify:_____________________

10a. Was this individual trained as a gatekeeper? Select one

• Yes [CONTINUE TO 9B]

• No [CONTINUE TO 10]

• Don’t Know [CONTINUE TO 10]

10b. (If yes to 9a), Please select the type of training the gatekeeper received

Select all that apply

QPR (Question, Persuade, Refer) ASIST (Applied Suicide Prevention Intervention Skills Training Lifelines SafeTALK Signs of Suicide (SOS) Connect Yellow Ribbon Youth Depression Suicide: Let’s Talk Response (A Comprehensive High School-based Suicide Awareness Program)

Sources of Strength Kognito AMSR (Assessing and Managing Suicide Risk) RRSR (Recognizing and Responding to Suicide Risk) Campus Connect Locally Developed, please specify: __________________­­­­­­­­­_________________ Other, please specify: ____________________________________ Don’t Know [CONTINUE TO 9C]

10c.. Please enter the approximate month and year the gatekeeper was most recently trained

Month Year

11. At the time of identification, was the youth screened for suicide risk (i.e. a screening tool was administered to determine whether the youth is at risk for suicide)? Select one. Select Yes, No, or Don’t Know and proceed to the follow-up questions.

 Yes, the youth was screened for suicide risk

No, the youth was NOT screened for suicide risk OR I Don’t Know if the youth was screened for suicide risk

11a. What screening tool was used? Select all that apply Patient Health Questionnaire (PHQ-9) Columbia Suicide Severity Rating Scale (CSSR-S) Behavioral Health Screen (BHS) Ask Suicide Screening Questions (asQ) Beck Depression Inventory (BDI) Suicide Behaviors Questionnaire (SBQ-R) Screening Tool in Signs of Suicide (SOS) Locally developed screening tool Don’t Know Other, please specify: __________________________________

11b. Was the youth determined to be in need of a referral? Select one Yes [GO TO SECTION 3] No [COMPLETE 10C] 11c. Please indicate why the youth was determined not to be in need of a referral:

SECTION 3: REFERRAL INFORMATION

11. Was the youth referred to mental health services and/or other supports as a result of having been identified as being at risk for suicide?

Select one. Select Yes, No, or Don’t Know and proceed to the follow-up questions

 Yes	 No	 I Don’t Know
12a. Please indicate the date of referral (mm/dd/yyyy) __ __ /__ __ / __ __ __ __	12d. Why not? Select one primary reason Youth was already receiving services or supports No capacity at provider agencies to receive a referral Unable to contact youth (e.g. youth moved out of state) Youth or Parent refused services Don’t Know Other, please specify: _____________ If the youth was not referred to any type of services, please end the form	12e. Why don’t you know? Select all that apply Parent permission for tracking required but not granted No tracking system in place Tracking system requires an agreement to share data but the data agreement is not in place Tracking system prohibits data sharing Parent or youth could not be contacted Don’t Know Other, please specify: ___________________ If you Don’t Know if the youth was referred to any type of services, please end the form
12b. To which of the following mental health services was the youth referred? Select all that apply. If the youth was not referred for MH Services, leave blank and continue to question 11d: Private Mental Health Agency or Provider Public Mental Health Agency or Provider (e.g. tribal or state sponsored mental health agency) Psychiatric Hospital/ Unit Substance abuse treatment center Emergency department School counselor School Based Health Clinic Mobile crisis unit Tribal/Cultural Service (e.g. sweat lodge, talking circle) Don’t Know Other, please specify: ________________________________ 12c. To which of the following other supports was the youth referred? Select all that apply. If the youth was not referred to other supports, please leave blank and continue to question 12: School or academic organization (e.g. school club, academic counseling, tutoring) Community based organization, recreation religious, afterschool program Family or extended family (e.g. parent, foster parent, grandparent, aunt, uncle) Physical health provider (e.g. pediatrician, primary care provider) Law enforcement/ Juvenile justice agency (e.g. pre-trial services, mental health court, police) Social service agency (e.g. child welfare, supportive housing) Crisis hotline (i.e. NSPL, local crisis hotline, text msg hotline) Don’t Know Other, please specify: ________________________________ IF YOU SELECTED A MENTAL HEALTH SERVICE IN SECTION 11B CONTINUE TO QUESTION 12. If the youth was only referred to OTHER SUPPORTS (i.e.you did not select any mental health services in section 11b), Please end the form

SECTION 4. FOLLOW-UP TO MENTAL HEALTH REFERRAL

11. Within the 3 months following the date of referral, did the youth receive a first mental health appointment as a result of the mental health referral? Select one. Select Yes, No, or Don’t Know and proceed to the follow-up questions

 Yes	 No	 I Don’t Know
13a. Please indicate the date of first mental health appointment (mm/dd/yyyy) __ __ /__ __ / __ __ __ __	13d. Why not? Select all that apply Made an appointment for youth, but youth did not attend Parent or youth refused service for personal reasons (i.e. not financial reasons) Youth was waitlisted for more than three months Youth did not have insurance or could not afford services Youth did not have transportation to the appointment Don’t Know Other, please specify: ______________ IF THE YOUTH DID NOT RECEIVE A FIRST MENTAL HEALTH APPOINTMENT, PLEASE END THE FORM	13f. Why don’t you know? Select all that apply Parent permission for tracking required but not granted No tracking system in place Tracking system requires an agreement to share data but the data agreement is not in place Tracking system prohibits data sharing Parent or youth could not be contact Other, please specify: ________________ IF THE YOUTH DID NOT RECEIVE A FIRST MENTAL HEALTH APPOINTMENT, PLEASE END THE FORM
13b. Zip code for the first mental health appointment __ __ __ __ __
13c. Which mental health service (s) did the youth receive at the first appointment? Select all that apply. Suicide risk assessment (e.g. initial risk assessment or re-assessment) Mental health assessment (e.g. assessment of psychosocial needs and conditions) Substance use assessment Mental health Counseling (e.g. outpatient group or individual counseling) Substance abuse counseling (e.g. inpatient or outpatient, group or individual) Medication Inpatient or residential psychological services Tribal or cultural services (e.g. traditional healing practices, talking circles, sweat lodge) Don’t Know Other, please specify:__________________
13f. At the time of the first service, was it determined that the youth was in need of a second mental health appointment? Yes (CONTINUE TO QUESTION 13) No (PLEASE END THE FORM) Don’t Know (CONTINUE TO QUESTION 13)

11. Did the youth receive a second mental health appointment within the three months following the initial referral? Select one. Select Yes, No, or Don’t Know and proceed to the follow-up questions

 Yes	 No	 I Don’t Know
14a. Date of Second mental health Appointment (mm/dd/yyyy) __ __ /__ __ / __ __ __ __	14d. Why not? Select all that apply Made an appointment for youth, but youth did not attend Parent or youth refused service for personal reasons (i.e. not financial reasons) Youth was waitlisted for more than three months Youth did not have insurance or could not afford services Youth did not have transportation to the appointment Don’t Know Other, please specify: ______________ PLEASE END THE FORM	14e. Why don’t you know? Select all that apply Parent permission for tracking required but not granted No tracking system in place Tracking system requires an agreement to share data but the data agreement is not in place Tracking system prohibits data sharing Parent or youth could not be contacted Other, please specify: ________________ PLEASE END THE FORM
14b. Zip Code for Second mental health appointment: __ __ __ __ __
14c. Which mental health service(s) did the youth receive at the second appointment? Select all that apply Suicide risk assessment (e.g. initial risk assessment or re-assessment) Mental health assessment (e.g. assessment of psychosocial needs and conditions) Substance use assessment Mental health Counseling (e.g. outpatient group or individual counseling) Substance abuse counseling (e.g. inpatient or outpatient, group or individual) Medication Inpatient or residential psychological services Tribal or cultural services (e.g. traditional healing practices, talking circles, sweat lodge) Don’t Know Other, please specify: ________________________________ PLEASE END THE FORM

State/Tribal EIRF-Individual Form Page 6

12/2015