Counseling Center

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SUICIDE INCIDENT REPORT FORM
The Counseling Center has a primary role in preventing suicide among SIUC students. By filling out this report, you will be alerting the Counseling Center to the fact that a particular student was recently, or still is, in a suicidal crisis. The Counseling Center will review your report and will take steps to insure that at-risk students come in for counseling.

Please print this form and fax it (453-6151) or transit it to the Counseling Center at Student Health Center, Room 253.

I. PERSONAL DATA
Please complete all sections for which you know the requested information.

1. STUDENT’S NAME
First Name Last Name

2. WHERE DOES THE PERSON LIVE?

       On-campus residence hall
       Southern Hills or Evergreen Terrace
       Sorority or Fraternity House
       Apartment or house, alone or with roommates
       With family members:      Parents        Partner/Spouse        Children

3. LOCAL ADDRESS

4. LOCAL PHONE NUMBER

5. CELL PHONE NUMBER

6. AGE

7. RACE

8. SEX male female

9. YEAR IN SCHOOL
                   Freshman                                        Graduate
                   Sophomore                                     Professional (law, medical)
                   Junior                                              Other
                   Senior                                             Don’t know

10. MAJOR

11. SOCIAL SECURITY NUMBER

II. INCIDENT INFORMATION

12. DATE INCIDENT OCCURRED

13. TIME INCIDENT OCCURRED AM PM

14. LOCATION OF INCIDENT (Give specific address in known)

15. Incident Narrative: Please describe the nature of the incident in detail, such as: verbal or written threat, self-harming behavior, details of suicide gesture or attempt, any events leading up to the behavior of concern, how did you learn of the event, how was the incident handled…

III. BACKGROUND INFORMATION

16. PRIOR COUNSELING: Is the student currently in counseling or has been in the past?

       Yes
       No
       Don’t Know

If yes, from whom and when?

17. PRIOR SUICIDAL BEHAVIOR: Has this person made a previous threat, gesture, or attempt?

       Yes
       No
       Don’t know

18. CONTACTS: Can you think of anyone who might be able to provide additional information about the incident (friend, roommate, residence life personnel)?

Name Phone Number Relationship to Student

Name Phone Number Relationship to Student
19. CONTACT INFORMATION FOR REPORT WRITER:

NAME

RELATIONSHIP TO STUDENT

DEPARTMENT

PHONE NUMBER

DATE OF REPORT

Thank you for your cooperation. Your action may save a student’s life.

Please fax or transit this form within 24 hours of the incident to:

Suicide Prevention Team
Counseling Center
Student Health Center Building, Rm. 253
Phone: 618-453-5371
Fax: 618-453-6151

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