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Screening for Mental Health Needs
Hope M. Siler, MSW, LSW
ASPEN Project Regional Director
www.wvaspen.com
OBJECTIVES
• Participants will be introduced to SAMHSA’s “Preventing Suicide: A High School Toolkit”
• Participants will learn the significance of suicide as a public health concern
• Participants will learn to utilize tools for screening for mental health (PHQ-9, ASAP-20)
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Preventing Suicide:A Toolkit for High Schools
This tool will help schools and communities:• Assess their ability to prevent suicide among
students and respond to suicides that may occur• Understand strategies that can help students
who are at risk for suicide• Understand how to respond to the suicide of a
student or other member of the school community
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Preventing Suicide:A Toolkit for High Schools
• Identify suicide prevention programs and activities that are effective for individual schools and respond to the needs and cultures of each school’s students
• Integrate suicide prevention into activities that fulfill other aspects of the school’s mission, such as preventing the abuse of alcohol and other drugs.
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Why Suicide Prevention in Schools?
Many high school students reported that they had seriously considered suicide in the past year
CDC,
2010a
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Why Suicide Prevention in Schools?
Suicide is the third leading cause of death among teenagers in the United States
CDC, 2009
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Why Suicide Prevention in Schools?
One out of every 53 high school students (1.9 percent) reported having made a suicide attempt that was serious enough to be treated by a doctor or a nurse
CDC,
2010a
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Why Suicide Prevention in Schools?
1. Maintaining a safe school environment is part of a school’s overall mission.
– Many activities designed to prevent violence, bullying, and the abuse of alcohol and other drugs can also reduce suicide risk among students (Epstein & Spirito, 2009).
– Programs that improve school climate and promote connectedness help reduce risk of suicide, violence, bullying, and substance abuse (Resnick et al., 1997; Blum, McNeely, & Rinehart, 2002).
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Why Suicide Prevention in Schools?
1. Maintaining a safe school environment is part of a school’s overall mission.
– Efforts to promote safe schools and adult caring also help protect against suicidal ideation and suicide attempts among LGB youth (Eisenberg & Resnick, 2006).
– Some activities designed to prevent suicide and promote student mental health can reinforce the benefits of other student wellness programs.
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Why Suicide Prevention in Schools?
1. Maintaining a safe school environment is part of a school’s overall mission.
2. Students’ mental health can affect their academic performance. – 1 out of 5 high school students receiving grades
of mostly D’s and F’s attempted
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Why Suicide Prevention in Schools?
1. Maintaining a safe school environment is part of a school’s overall mission.
2. Students’ mental health can affect their academic performance.
3. A student suicide can significantly impact other students and the entire school community. – Knowing what to do following a suicide is critical to
helping students cope with the loss and prevent additional tragedies that may occur.
– Adolescents can be susceptible to suicide contagion
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Why Suicide Prevention in Schools?1. Maintaining a safe school environment is part of a school’s overall
mission.2. Students’ mental health can affect their academic performance.3. A student suicide can significantly impact other students and the
entire school community.
4. Schools have been sued for negligence for the following reasons– Failure to notify parents if their child appears to be suicidal – Failure to get assistance for a student at risk of suicide – Failure to adequately supervise a student at risk
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(Doan, Roggenbaum, & Lazear, 2003; Juhnke, Granello, & Granello, 2011; Lieberman, 2008–2009; Lieberman, Poland, & Cowan, 2006)
How Schools Can Prevent Suicides
• Protocols for helping students at risk of suicide
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How Schools Can Prevent Suicides
• Protocols for helping students at risk of suicide
• Protocols for responding to suicide death
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How Schools Can Prevent Suicides
• Protocols for helping students at risk of suicide
• Protocols for responding to suicide death
• Staff education training
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How Schools Can Prevent Suicides
• Protocols for helping students at risk of suicide
• Protocols for responding to suicide death
• Staff education training
• Parent education
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How Schools Can Prevent Suicides
• Protocols for helping students at risk of suicide
• Protocols for responding to suicide death
• Staff education training
• Parent education
• Student education
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How Schools Can Prevent Suicides
• Protocols for helping students at risk of suicide
• Protocols for responding to suicide death
• Staff education training
• Parent education
• Student education
• Screening
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Chapter 1GETTING STARTED
The two essential components that every school should have in place are:
• Protocols for helping students at possible risk of suicide (PREVENTION)
• Protocols for responding to a suicide death (POSTVENTION)
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Chapter 1GETTING STARTED
Step 1. Engage administrators, school boards, and other key players. – Explain why it is important to address suicide
risk among students. – Highlight data and information specific to your
district, State, or tribe. – Share your plans.
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SCHOOL STAFF RESPONSIBILITIES
Superintendent * Curriculum director * Principal
Assistant principal * Teachers * Technology staff Health
educator * Athletic staff * School nurse
School health coordinator * school counselor
Guidance counselor * School social worker
Student assistance program staff * pupil services
School psychologist * Special education staff
Members of the Crisis Response * school resource officer
School-based health center and/or mental health center staff
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Chapter 1GETTING STARTED
Step 2. Bring people together to start the planning process. – Engage school staff. – Engage community partners
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Chapter 1GETTING STARTED
COMMUNITY PARTNERSCommunity Youth Center * Cultural Communities Leaders Mental health providers * Community mental health agencies
Substance abuse counselors * Crisis center workers Healthcare providers * Community health department staff
Hospital, ER staff * EMT’s * Fire & Rescue personnel First responders * Coroner
Police * Clergy * County social services staff Child welfare providers * Juvenile justice professionals
Media representatives * Immigrant & Refugee organization staff LGBT youth–serving program staff * YMCA * Boys & Girls Club
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Chapter 1GETTING STARTED
Step 3. Provide key players with basic information about youth suicide and suicide prevention.
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RISK FACTORS
• Behavioral Health Issues/Disorders
• Personal Characteristics
• Adverse/Stressful Life Circumstances
• Risky Behaviors
• Family Characteristics
• Environmental Factors
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RISK FACTORS
• Behavioral Health Issues/Disorders– Depressive disorders– Substance abuse or dependence– Conduct/disruptive behavior disorders– Other disorders (anxiety, personality, etc.)– Previous suicide attempts– Self-injury (without intent to die)– Genetic/biological vulnerability
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RISK FACTORS
• Personal Characteristics– Hopelessness– Low self-esteem– Loneliness– Social alienation and isolation, lack of belonging– Low stress and frustration tolerance– Impulsivity– Risk-taking, recklessness– Poor problem-solving or coping skills– Perception of self as very underweight or very overweight– Capacity to self-injure– Perception of being a burden
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RISK FACTORS
• Adverse/Stressful Life Circumstances– Interpersonal difficulties or losses– Disciplinary or legal problems– Bullying, either as victim or perpetrator– School problems– Physical, sexual, and/or psychological abuse– Chronic physical illness or disability– Exposure to suicide of peer
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RISK FACTORS
• Risky Behaviors – Alcohol or drug use– Delinquency– Aggressive/violent behavior– Risky sexual behavior
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RISK FACTORS
• Family Characteristics– Family history of suicide or suicidal behavior– Parental mental health problems– Parental divorce– Death of parent or other relative– Problems in parent-child relationship
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RISK FACTORS• Environmental Factors
– Negative social and emotional environment– Lack of acceptance of differences– Expression and acts of hostility– Lack of respect for the cultures of all students– Limitations in school physical environment– Weapons on campus– Poorly lit areas conducive to bullying and violence– Limited access to mental health care– Access to lethal means, particularly at home– Exposure to other suicides, leading to suicide
contagion– Exposure to stigma and discrimination
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PROTECTIVE FACTORS
• Individual Characteristics and Behaviors
• Family and Other Social Support
• School
• Mental Health and Healthcare Providers and Caregivers
• Access to Means
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WALL OF RESISTANCEWALL OF RESISTANCE
www.wvaspen.com There is HOPE. Ask for HELP. Choose LIFE. Suicide Prevention Lifeline 1-800-273-TALK (8255)
WARNING SIGNS“IS PATH WARM”
• I…ideation• S…substance abuse• P…purposelessness• A…anxiety• T…trapped• H…hopelessness• W…withdrawal• A…anger• R…recklessness• M…mood changes (sudden, positive or negative)
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Suicide Crisis Episode
Years Days Hours Days Years
Ris
k Le
vel
Stable Stable
Hazard Encountered
Crisis Begins
Crisis Peaks
Risk Imminent
Crisis Diminishes
Plus or minus three weeks www.wvaspen.com There is HOPE. Ask for HELP. Choose LIFE. Suicide Prevention Lifeline 1-800-273-TALK (8255)
The Many Paths to Suicide
WA
LL OF
RE
SIS
TA
NC
E
Fundamental Risk Acute Risk Cause of Death
Biological
Personal/Psychological
Environmental
Increased hopelessness serious contemplation
Poison
Firearm
Hanging
Jumping
Autocide
www.wvaspen.com There is HOPE. Ask for HELP. Choose LIFE. Suicide Prevention Lifeline 1-800-273-TALK (8255)
Stopping the chain reaction anywhere = PREVENTION
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NATIONAL DATAAges 13-19
• 2009, 1,852 young people died by suicide
• Suicide is the 3rd leading cause of death
• For every completed suicide death, there is 100-200 attempts (1 every 60 seconds)
• For every suicide death, there is at least 6 survivors left behind
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NATIONAL DATAYRBS Report
• 1/53 high school students reported having made a suicide attempt that was serious enough to be treated by a doctor or nurse
• 1/16 high school students reported having attempted suicide at lease once.
• 1/9 had made a plan about how to attempt suicide
• 1/7 reported having seriously considered attempting suicide during the preceding 12 months
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West Virginia Data15-24 Years
2000-2009
www.wvaspen.com Suicide Prevention Lifeline 1-800-273-TALK (8255)
Ask for HELP.
Choose LIFE.
There is HOPE.
Barbour
Berkeley
Boone
Braxton
Brooke
CabellClay
Fayette
Gilmer
Grant
Greenbrier
Hampshire
Hancock
Hardy
Harrison
Jackson
Kanawha
Lewis
Lincoln
Logan
McDowell
Marion
Mason
Mercer
Mineral
Mingo
Monongalia
Monroe
Morgan
Nicholas
Ohio
Pendleton
Pocahontas
Preston
Putnam
Raleigh
Randolph
Ritchie
Roane
Summers
Taylor
Tucker
Tyler
Upshur
Wayne
Webster
Wetzel
Wirt
Wood
Wyoming
JeffersonPleasantsDodd-ridge
Cal-houn
4 (12.26)
4 (12.56)
7 (10.81))
12 (29.79)
Marshall
10 (3.97)
5 (26.13)
4 (19.02)
2 (10.22)
3 (15.30)
4 (34.13))
2 (12.97)
2 (16.07)
3 (20.28)
7 (20.00))2 (7.78)
3 (18.15)
11 (9.89)
2 (20.60)
3 (26.51)
18 (10.32)4 (30.34)
47 (20.96))
9 (20.92)
2 (6.79)
10 (10.55)
2 (13.69)3 (8.81)
8 (20.23))
6 (9.75)
West Virginia Suicides by countyAges 15-242000-2009
Rate per 100,000 Population
WV Average Rate 13.2/100,000320 Deaths by Suicide
18.15 – 46.92
12.26 – 16.39
10.07 – 11.34
0.00 – 9.89
Suicide:
A PREVENTABLE DEATH IN OUR STATE
5 (46.92)
12 (160.5)
4 (14.53)
2 (22.25)
2 (6.68)
1 (13.19)
5 (15.89)
6 (16.39)
1 (9.88)
3 (9.01)
1 (5.34)0 (0.00)
16 (27.19)
13 (15.36)
1 (3.47)
3 (8.30)
3 (10.07)
4 (10.52)
10 (16.14)
11 (12.38)
0 (0.00)
1 (13.66)
10 (9.68)
5 (9.63)
0 (0.00)
2 (11.34)
www.wvaspen.com There is HOPE. Ask for HELP. Choose LIFE. Suicide Prevention Lifeline 1-800-273-TALK (8255)
Chapter 1 GETTING STARTED
Step 4: Develop your overall strategy.– Assess your current policies, programs and
school culture
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No one is safe from the risk of suicide – wealth,
education,
intact family, or
popularity
cannot protect us from this risk
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Chapter 2PROTOCOLS FOR HELPING STUDENTS
AT RISK FOR SUICIDE
WHY IS IT IMPORTANT TO BE PREPARED TO HELP STUDENTS AT RISK OF SUICIDE?
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Chapter 2PROTOCOLS FOR HELPING STUDENTS
AT RISK FOR SUICIDE
Why is it important to be prepared…?• Maintain a safe and secure school environment
• Promote the behavioral health of students, which enhances their academic performance
• Avoid liability related to suicides or suicide attempts by students
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Chapter 2PROTOCOLS FOR HELPING STUDENTS
AT RISK FOR SUICIDE
• Suicide risk resources• Self-injury and suicide risk information• Guidelines for notifying parents• Parent contact acknowledgement form• Guidelines for student referrals• Student suicide risk documentation form• Protocol for responding to a student suicide attempt• Guidelines for facilitating a student’s return to school
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Chapter 3AFTER A SUICIDE
• Immediate response protocol• Sample script for office staff• Sources of postvention consultation• Guidelines for working with the family• Guidelines for notifying staff• Sample announcements• Sample letter to families• Talking points for students and staff after a suicide• Guidelines for Memorialization• Guidelines for working with the media• Long-term response protocol• Guidelines for anniversaries of a death
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Chapter 3AFTER A SUCIDE
• Key Terms:– Survivor: a person who has experienced the suicide
of a family member, friend, or colleague– Attempt survivor: a person who attempts suicide but
does not die – Postvention: refers to programs and interventions for
survivors following a death by suicide– Suicide contagion: is “a process by which the
suicide or suicidal behavior of one or more persons influences others to commit or attempt suicide” (Davidson and Gould, 1989)
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Chapter 4STAFF EDUCATION & TRAINING
• All staff should be…– Aware of risk of suicide– Aware that the school is taking steps to
reduce suicide risks– Trained to recognize the warning signs– Able to take action if they become aware of a
student who displays suicide warning signs
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Chapter 4STAFF EDUCATION & TRAINING
• NREPP (National Registry for Evidenced-Based Prevention Practices) Gatekeeper Trainings:– Lifelines
• BPR (Best Practice Registry) Gatekeeper Trainings:– QPR (Question, Persuade, Refer)– More Thank Sad– safeTALK– ASIST
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Chapter 5PARENT/GUARDIAN EDUCATION & OUTREACH
• Education and outreach programs– NREPP (National Registry for Evidenced-Based Prevention Practices)
• Lifelines
– BPR (Best Practice Registry)
• Not My Kid (17-minute video online)
• Facts For Parents (handout)– Designed to educate and gain support for
implementation of initiatives
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Chapter 5PARENT/GUARDIAN EDUCATION & OUTREACH
• Effective programs should include…– Identifying students at possible risk and referring them
to appropriate services– Responding appropriately to a suicide death– Providing training and suicide awareness education
for staff– Educating parents regarding suicide risk and mental
health promotion– Educating and involving students in mental health
promotion and suicide prevention efforts– Screening students for suicide risk
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Chapter 6STUDENT PROGRAMS
• Types of programs (3):– Curricula for all students
• Provide information about suicide prevention• Promote positive attitudes• Increase student’ ability to recognize if they or their
peers are at risk for suicide• Encourage students to seek help for themselves
and their peers
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Chapter 6STUDENT PROGRAMS
• Types of programs:– Skill-building programs for at-risk students
• Help protect at-risk students from suicide by – Building their coping, problem-solving, and cognitive
skills– Addressing related problems such as depression and
other mental health issues, anger, and substance abuse
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Chapter 6STUDENT PROGRAMS
• Types of programs:– Peer leader programs
• Teach selected students skills to identify and help peers who may be at risk.
• Some teach connectedness among students and also between students and staff
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Chapter 7SCREENING
• Ideas for maximizing parental response rate
• Screening programs– NREPP (National Registry of Evidenced-Based Prevention Practices)
• www.sprc.org/bpr/section-i-evidence-based-programs
• SOS Signs of Suicide
– BPR (Best Practice Registry)
• www.sprc.org/bpr/section-iii-adherence-standards • More Than Sad
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Chapter 7SCREENING
• Identifying Students at Risk, Alternatives:– Academic achievement– Effort– Conduct– Attendance– Negative report card comments– Code of student violations– Involvement with school police
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Chapter 7SCREENING
• Active Parental Consent– Definition: a student can participate only if the parent
gives explicit permission, in writing– Pros: ensures parents are informed and their
approval is obtained. This engagement increases the likelihood that parents will help their child obtain treatment, if it is needed.
– Cons: often difficult to get responses from parents and takes more staff time; fewer students likely to be screened.
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PHQ-9 Screening Questionnaire
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•The Patient Health Questionnaire Modified for Teens (PHQ-9 Modified) can be used with patients between the ages of 12 and 18 and takes less than five minutes to complete and score.
•Patients should be informed of their confidentiality rights before the PHQ-9 Modified is administered.
PHQ-9 Screening QuestionnaireSCORING…
• For every “X”– Not at all = 0– Several days = 1– More than half the days = 2– Nearly every day = 3
• Add up all the “X”ed boxes = total score
• Total score > 11 are POSITIVE
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PHQ-9 Screening Questionnaire
• Regardless of the PHQ-9 Modified total score, endorsement of serious suicidal ideation OR past suicide attempt (questions 12 and 13 on the screen) should be considered a positive screen.
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PHQ-9 Screening Questionnaire
INTERPRETATION…
• The questionnaire indicates only the likelihood that a youth is at risk for depression or suicide; its results are not a diagnosis or a substitute for a clinical evaluation.
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PHQ-9 Screening Questionnaire
DEPRESSION…
• The overall score on the PHQ-9 Modified provides information about the severity of depression, from minimal depression to severe depression.
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PHQ-9 Screening Questionnaire
• Total Score: Depression Severity• 1–4: Minimal depression• 5–9: Mild depression• 10–14: Moderate depression (≥ 11 = Positive
Score)• 15–19: Moderately severe depression• 20–27: Severe depression
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ASAP-20Adolescent Suicide Assessment Protocol
• 20 items divided into 5 subgroups– Historical items (#1-4)– Clinical items (#5-9)– Specific suicidality items (#10-12)– Context items (#13-18)– Protective factor items (#19-20)
• Other considerations
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ASAP-20Adolescent Suicide Assessment Protocol
Actions Taken1. Continue monitoring risk factors 2. Notify family 3. Notify/consult with supervisor 4. Recommend/refer to outpatient treatment 5. Recommend/refer to psychiatric consult/med evaluation6. Contract for NO SUICIDAL behaviors 7. Recommend elimination of access to firearms/poisons 8. Notify legal authorities &/or CPS of risk to self/or others 9. Recommend/refer to day treatment 10. Recommend/refer to crisis unit/voluntary hospitalization 11. Initiate involuntary hospitalization 12. Other:
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ASAP-20Adolescent Suicide Assessment Protocol
• SCORING…– No = 0– Mild = 1– Moderate = 2– Severe = 3
– Risk level (total score of all 20 items)• Low = 0-15• Medium = 16-19• High = 20+
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QUESTIONS or THOUGHTS
wvsuicidecouncil.orgwvaspen.com
sprc.orgafsp.org
spanusa.orgsuicidology.org
jasonfoundation.orgthetrevorproject.orgjedfoundation.org
Suicide Prevention Lifeline1-800-273-TALK (8255)
RESOURCES
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Your willingness to listen and to help can rekindle hope.
HOPE MAKES ALL THE DIFFERENCE.