Suicide Prevention Form

Suicide Concern Report Form

Important note: The Suicide Concern Reports are not reviewed after-hours, on the weekends, or during university holidays or breaks. If you consider the situation to be an emergency, please contact 911 to report your concerns.

Central Washington University has an investment in the welfare and well-being of all students. In its efforts to ensure the general well-being of all students, staff and faculty the university has implemented a suicide prevention program. The programs goal is to assess students that have engaged in suicide-related behavior in order to evaluate their level of risk and provide them with professional mental health services.

The Suicide Concern Report Form is used to inform the Student Consultation Team that a student has engaged in suicide-related behavior. Such suicide-related behavior can include making suicide threats verbally or nonverbally (e.g., through writing) as well as engaging in intentional self-injurious behavior with the intent to attempt suicide and/or to give the appearance of intending to kill him/herself.

Any concerned party can complete the Suicide Concern Report Form. Once the form is completed it is sent to the Suicide Prevention Team and the Student Consultation Team for review and disposition. If action is taken on the basis of the report, the student will be contacted by the Office of Student Rights and Responsibilities and directed to contact the Student Counseling Center Case Manager for compulsory risk assessment. Again, the ultimate goal is to provide the student with mental health services in order to assist the student in developing more adaptive ways to cope and adjust to psychological stress and strain.

Student Information

Student's Name:
Student's Phone Number:
Student's Age:
Student's Gender: Male Female Trans
Student's Academic Year:
Was the incident on campus?
Yes
No
Address of student (if any known):

Incident Information

Incident Date:
Incident Time:
Incident Location:

Describe any threats in which the student proposed harm, but did not act:


Were actions taken representing intent to harm oneself?


Once the threat and/or actions became known, what were the immediate responses?


Background Information

To the best of your knowledge, has this student made prior threats or actions?
Yes
No
Unknown

Are there others able to provide additional information about the incident (e.g. roommate, friend, etc.)?

Name 1:


Phone 1:


Relationship to Student 1:


Name 2:


Phone 2:


Relationship to Student 2:

Information about author of report:

Name:


Relation to Student:


Dept., Agency, or Service:


Phone:


Date of Report: