West Geauga School Risk Assessment Form 

Assessment of Student’s Risk to Self (to be used as an initial screening tool) 

Evaluator’s Name/Title​: ​Click or tap here to enter text. ​Date​: ​Click or tap to enter a date.​ S​ chool​: ​Choose an item.

Student’s Name​: ​Click or tap here to enter text.​ ​DOB​: ​Click or tap to enter a date.​ Age​: ​Choose an item.​ ​Sex​: ​Choose an
item.​ ​Grade​: ​Choose an item.

1. What does the student say?

Click or tap here to enter text.

2. Risk Factors (Check all that apply):

Any Known Alcohol/Drug Use ☐​ Yes ☐​
No
Psychiatric History ☐​ Yes ☐​
No
High Stress Level ☐​ Yes ☐​
No
Preoccupation with Death and Dying ☐​ Yes ☐​
No
Depression ☐​ Yes ☐​
No
Feelings of Hopelessness ☐​ Yes ☐​
No

3. What other emotions are present?

☐​​Anger ​☐​Frustration ​☐​Rejection ​☐​Self-Hate ​☐​Revenge ​☐​Indifference
☐​Other ​Click or tap here to enter text.

4. Self-injurious behavior?​ ​☐Y​es ​☐​No

Details: ​Click or tap here to enter text.

5. Past or current thoughts of suicide?​ ​☐​Yes ​☐​No

6. Suicide Plan? ​☐Y​es ​☐​No

Suicide Plan Details (Specificity, Lethality, Availability): ​Click or tap here to enter text.

7. Suicide Attempts – Recent or Past? ​☐​Yes ​☐​No

Details (Date, Time, Detail of Last Attempt): ​Click or tap here to enter text.

8. Family History of Suicidal Ideation/Attempts/Suicide​? ​☐​Yes ​☐​No

If Yes, Provide Details​: ​Click or tap here to enter text.

9. Any Other Precipitating Events (Friend/Family Death, Major Changes at Home, etc.)?​ ​☐​Yes ​☐N
​o
If Yes, Provide Details: ​Click or tap here to enter text.

10. Risk Assessed​: ​☐​None ​☐​Minimal ​☐​Possible ​☐​Significant

11. Safety/Follow-Up Plan​: ​Click or tap here to enter text.

Staff Signature​: __________________ ​Date​: ________ ​Administrator Signature​: __________________ ​Date​: ________