FFB(EXHIBIT) - STUDENT WELFARE: CRISIS INTERVENTION

Exhibit A–Authorization Form for Conducting a StudentInterview Without Parent Consent

Principal or Responsible Person

Azle Independent School districtDate

Regarding:Student's Name

The undersigned, a representative of the Texas Department of Protective and Regulatory Services, hereby certifies as follows:

  1. That I am in the process of investigating a report that the above-referenced minor student has been the subject of child abuse or neglect;
  2. That the child might be subjected to further physical, emotional, or sexual harm if it were necessary to obtain parental consent prior to conducting a personal interview or examination;
  3. That pictures of the child or a videotape of the child may be made in the process of the interview and examination; and
  4. That a request may be made to visit in the school with any other child or children in the home of the above-referenced minor student. Under Section 261.302 of the Texas Family Code, the Department of Protective and Regulatory Services has the right to interview the child "at any reasonable time and at any place including the child's school."

Authorized RepresentativeTexas Department of Protective and Regulatory Services

When an authorized representative of the Texas Department of Protective and Regulatory Services requests to interview a child in connection with an investigation of a child abuse report, you should:

  1. Ensure that the requesting party has proper identification (badge or identification card);
  2. Obtain the representative's signature on this form; and
  3. Allow the visit

Representatives from the Texas Department of Protective and Regulatory Services are authorized to take the children they interview to another location if they deem it necessary. Local campus guidelines should be followed in checking the child out of school. District personal may offer to accompany the representative in such situations.

Exhibit B–Suicide Intervention Protocol

Any school employee who identifies a student as expressing the desire to harm him- or herself or others is to contact the counselor or an administrator immediately. The District will adhere to the following guidelines:

  1. The student is to remain under adult supervision at all times.
  2. The student will be immediately referred to the intervention counselor, who will facilitate an intervention.
  3. The counselor will complete an interview.
  4. The counselor will complete a suicidal ideation lethality assessment.
  5. Based on the assessment, the District will adhere to the following parameters:
    1. If the counselor determines that the student is at low risk, the following guidelines shall be followed:
      1. Parent contact
        1. Provide resources
      2. Follow-up by counselor
    2. If the counselor determines that the student is at moderate to high risk, the following guidelines shall be followed:
      1. Inform campus administrator
      2. Student to remain under adult supervision
      3. Call and meet with parent
        1. Inform parent of urgency of situation
        2. Ensure student is supervised including during parent conference (if student isn't involved)
        3. Give specific recommendations to parents such as:
          1. Closely supervise
          2. Secure all guns, knives, pills, etc. in the home
        4. Have parent sign the suicide intervention notification and resources form
        5. Copy the form, giving copy to parent and maintaining an original in the counselor's personal confidential file
        6. Request parent follow-up with counselor on action taken via phone.
        7. Follow up by intervention counselor
          1. In the event that a student enters treatment, the intervention counselor will initiate a safety plan upon student's return.

In the event that a parent/responsible adult refuses to come to school to meet with the counselor and pick up their student, the counselor will notify and consult with an administrator.

With consent from the administrator, transportation via the school resource officer to the emergency room may take place.

In such a scenario, a student may never be sent home on the bus, walk, ride with a friend, or the like.

Exhibit C–Elementary Counselor Suicide Interview Questions

Name:Date:

Campus: ___________________________Counselor ___________________________

Student was self-referred or referred by another student based on information he/she shared.

Student was referred by a teacher based on information he or she shared.

Student turned in a writing assignment or drawing of concern (copy and attach).

Please ask the following questions to the student and document the answers.

  1. If the student drew a picture, ask the student about it. If the student made a statement, clarify exactly what the student said, what it meant, and why it was said.
  2. Have you ever felt like hurting yourself on purpose?
  3. Have you ever tried to hurt yourself before?
  4. Have you ever tried to hurt someone else before?
  5. Have you thought about how you might do this? Check to see if the students have access to projected items.
  6. Have you thought about when you might try this?
  7. Have you talked with anyone about these feelings?

Counselor Action:

_____Notification of Administrator - Document who spoken with, date & time, and notes of conversation.

_____Intervention - Documentation of person spoke with, date & time, and notes of conversation.

Document any follow-up sessions with the student.

Document any follow-up sessions with the parent(s).

Parent Consult Information:

Notes:

Exhibit D–Secondary Counselor Suicide Interview Questions

Name:Date:

Campus: ___________________________Counselor ___________________________

Student was self-referred or referred by another student based on information he/she shared.

Student was referred by a teacher based on information he/she shared.

Student turned in a writing assignment or drawing of concern (copy and attach).

Please ask the following questions to the student and document the answers.

  1. Statement or reason why the student was referred:
  2. If the student drew a picture or wrote a poem or paper, ask the student about it. If the student made a statement, clarify exactly what the student said, what it meant, and why it was said.
  3. Have you ever thought about killing yourself? If yes, when was the last time you had those thoughts?
  4. How often do you have those thoughts?
  5. Have you ever thought about a plan? If yes, how would you do it?
  6. Do you have access to these items (pills, weapons, etc.)?
  7. Have you ever tried to kill yourself in the past? If yes, how?
  8. Are you talking to anyone–such as a friend, parent, counselor, or other adult–about this or any other problems?

Counselor Action:

_____Notification of Administrator - Document who spoken with, date & time, and notes of conversation.

_____Intervention - Documentation of person spoke with, date & time, and notes of conversation.

Document any follow-up sessions with the student.

Document any follow-up sessions with the parent(s).

Parent Consult Information:

Notes:

Exhibit E–Counselor Suicidal Ideation Lethality Assessment

Name of student:Date:

Completed by:

Intensity of Risk Assessment

Totals:Column 1:_____Column 2:_____Column 3:_____

Scoring:

  1. Put the total from column one here
  2. Multiply the total from column 2 by 2 and put the total here:
  3. Multiply the total from column 3 by 3 and put the total here:
  4. Add all three scores and divide by 3.
  5. Final risk assessment:
    1. Low: 1-6
    2. Moderate: 7-10
    3. High: 11-13

Note: Risk assessments cannot be performed with complete accuracy, and do not predict with certainty the future behavior of this student. The findings and recommendations contained in this assessment represent the best professional judgment of the examiner.

Exhibit F–Parent Intervention Notification and Resources Form

By signing the following I am acknowledging that my child has engaged in disruptive behavior and/or verbalized suicidal intent. I understand that it is my responsibility to seek help for my child upon departure from the school campus. I have been provided a copy of resources that I may choose to use to seek this help. In understand that this list if not inclusive and other referrals from my child's doctor, insurance, and local agencies are other options available to me. I also understand that any fees, charges, or other financial obligation associated with a follow-up assessment and/or treatment by the providers listed below, or any other resources to which I might take my child, are not the responsibility of the District. I further understand that choosing not to seek help for my child may result in a referral to Child Protective Services and/or law enforcement as required by law.

Print Parent NameParent Signature

Counselor SignatureDate

Behavior Intervention Resources

Hospitals and Mental Health Facilities

Hotline Numbers

In the event of an emergency, call 911.

Azle ISD

FFB(EXHIBIT)-X

LDU 2019.01

DATE ISSUED: 9/13/2019