DJJ Form MHSA005 "Follow-Up Assessment of Suicide Risk" - Florida

What Is DJJ Form MHSA005?

This is a legal form that was released by the Florida Department of Juvenile Justice - a government authority operating within Florida. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on August 1, 2006;
  • The latest edition provided by the Florida Department of Juvenile Justice;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of DJJ Form MHSA005 by clicking the link below or browse more documents and templates provided by the Florida Department of Juvenile Justice.

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Download DJJ Form MHSA005 "Follow-Up Assessment of Suicide Risk" - Florida

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FLORIDA DEPARTMENT OF JUVENILE JUSTICE
F
-U
A
S
R
OLLOW
P
SSESSMENT OF
UICIDE
ISK
Youth’s Name
JJIS Number
Sex
Race
DOB
Facility/Program
Circuit
2. M
A
:
ETHOD OF
SSESSMENT
(FOLLOW-UP ASSESSMENT MUST INCLUDE INTERVIEW WITH YOUTH
AND COLLATERAL INFORMANTS)
___ Review of DJJ file
___ Interview with Parent
___ Interview with youth
___ Interview with Facility Nurse, Direct Care Staff, Facility Administration (Circle one)
___ Depression Inventory
___Suicide Risk Index/Questionnaire/Rating Scale (Attach Instrument)
: (Place  in applicable box)
3. C
M
S
URRENT
ENTAL
TATUS
WNL*
MODERATE
SERIOUS
SEVERE
Appearance
WNL
Appears dirty, disheveled,
Severe body odor and poor
Smells of urine or feces
unkempt
hygiene evident
Attitude during
WNL
Moderately uncooperative but
Markedly inappropriate (e.g.,
Extremely inappropriate to
Interview
otherwise appropriate
irritable, seductive, aggressive)
situation
to situation
to situation
Motoric
WNL
Some physical motor retardation
Serious psychomotor
Severe physical motor
Behavior
or motor agitation
retardation or agitation
retardation or agitation
Hostility or
WNL
Appears angry and admits anger
Verbally abusive
Physically threatening
Irritability
Affect
WNL
Minimal spontaneous affect or
Blunted affect or affect
Unchanging affect or
strange affect observed
incongruous with thoughts
bizarre actions
Depression
WNL
Appears sad and reports
Cries excessively, sleep or
Depressed and thinks
sadness
appetite disturbance
about death or suicide
Anxiety
WNL
Reports periods of persistent
Frightened, shaky, panic
Hyperventilation or panic
tension or unexplained fears
attack, hyperventilation within
attacks within past month
past 3 months.
Speech
WNL
Pressured or latency of speech
One word responses with no
Slurring, mute or
elaboration
incoherent
Insight and
WNL
Limited judgment and insight
Poor judgment and insight
Impaired judgment
Judgment
Perceptual
None
Feelings of unreality but denies
Reports hallucination within the
Appears to be having
Disorders
hallucinations
past month
hallucinations
*WNL = WITHIN NORMAL LIMITS
4. CURRENT/RECENT
SUICIDE RISK INDICATORS (Record youth’s statements and collateral information)
Yes
No
Is the youth currently thinking about hurting or killing himself or herself?
Does the youth have a plan/method for self-injury or suicide?
Is the youth currently self-injurious or has recently been self-injurious?
Does the youth express hopelessness/helplessness?
Has the youth experienced a recent significant loss, trauma or significant stressors?
Does the youth have medical problems (sickness, somatic complaints or chronic illness)?
Has there been recent behavioral changes or overt change in the youth’s clinical condition?
Does the youth exhibit neurovegetative signs of depression?
Rule 63N-1
MHSA 005
August 2006
Page 1 of 3
FLORIDA DEPARTMENT OF JUVENILE JUSTICE
F
-U
A
S
R
OLLOW
P
SSESSMENT OF
UICIDE
ISK
Youth’s Name
JJIS Number
Sex
Race
DOB
Facility/Program
Circuit
2. M
A
:
ETHOD OF
SSESSMENT
(FOLLOW-UP ASSESSMENT MUST INCLUDE INTERVIEW WITH YOUTH
AND COLLATERAL INFORMANTS)
___ Review of DJJ file
___ Interview with Parent
___ Interview with youth
___ Interview with Facility Nurse, Direct Care Staff, Facility Administration (Circle one)
___ Depression Inventory
___Suicide Risk Index/Questionnaire/Rating Scale (Attach Instrument)
: (Place  in applicable box)
3. C
M
S
URRENT
ENTAL
TATUS
WNL*
MODERATE
SERIOUS
SEVERE
Appearance
WNL
Appears dirty, disheveled,
Severe body odor and poor
Smells of urine or feces
unkempt
hygiene evident
Attitude during
WNL
Moderately uncooperative but
Markedly inappropriate (e.g.,
Extremely inappropriate to
Interview
otherwise appropriate
irritable, seductive, aggressive)
situation
to situation
to situation
Motoric
WNL
Some physical motor retardation
Serious psychomotor
Severe physical motor
Behavior
or motor agitation
retardation or agitation
retardation or agitation
Hostility or
WNL
Appears angry and admits anger
Verbally abusive
Physically threatening
Irritability
Affect
WNL
Minimal spontaneous affect or
Blunted affect or affect
Unchanging affect or
strange affect observed
incongruous with thoughts
bizarre actions
Depression
WNL
Appears sad and reports
Cries excessively, sleep or
Depressed and thinks
sadness
appetite disturbance
about death or suicide
Anxiety
WNL
Reports periods of persistent
Frightened, shaky, panic
Hyperventilation or panic
tension or unexplained fears
attack, hyperventilation within
attacks within past month
past 3 months.
Speech
WNL
Pressured or latency of speech
One word responses with no
Slurring, mute or
elaboration
incoherent
Insight and
WNL
Limited judgment and insight
Poor judgment and insight
Impaired judgment
Judgment
Perceptual
None
Feelings of unreality but denies
Reports hallucination within the
Appears to be having
Disorders
hallucinations
past month
hallucinations
*WNL = WITHIN NORMAL LIMITS
4. CURRENT/RECENT
SUICIDE RISK INDICATORS (Record youth’s statements and collateral information)
Yes
No
Is the youth currently thinking about hurting or killing himself or herself?
Does the youth have a plan/method for self-injury or suicide?
Is the youth currently self-injurious or has recently been self-injurious?
Does the youth express hopelessness/helplessness?
Has the youth experienced a recent significant loss, trauma or significant stressors?
Does the youth have medical problems (sickness, somatic complaints or chronic illness)?
Has there been recent behavioral changes or overt change in the youth’s clinical condition?
Does the youth exhibit neurovegetative signs of depression?
Rule 63N-1
MHSA 005
August 2006
Page 1 of 3
Youth’s Name
JJIS #
5. D
D
Y
P
S
:
EGREE OF
ANGEROUSNESS
OUTH
RESENTS TO
ELF
(Address and check off each indicator listed)
IMMINENCE OF BEHAVIOR
Comments:
____no recent or current suicidal thoughts or suicide risk behaviors
____recent or current non-specific thoughts of death
____recent or current specific thoughts of suicide or self-injury
____recent or current self-injurious behaviors
INTENT OF BEHAVIOR
Comments:
____no recent or current desire to die or harm self
____recently or currently feels would be better off dead
____recent or currently wants to hurt him/herself
____recently or currently wants to die/has lost the will to live
PLAN
Comments:
____denies plans to harm self
____detailed plan in the past, not at present
____current non-specific/vague plan
____current specific plan for self-injury or suicide
LETHALITY
Comments:
____denies plan to harm self
____unclear plan, lethality cannot be determined
____plan for self-injury could result in serious harm & could be lethal
____plan, if carried out would be lethal
6. I
P
S
R
?
Y
N
S YOUTH A
OTENTIAL
UICIDE
ISK
ES
O
S
F
W
S
Y
C
:
UMMARY OF
INDINGS
HICH
UPPORT
OUR
ONCLUSION
7. R
R
S
P
:
ECOMMENDATIONS
EGARDING
UICIDE
RECAUTIONS
Emergency Transport
(Baker Act)
NOTE: Youth presenting an imminent threat of suicide must be
transported for emergency care.
Precautionary Observation
Continue youth on Precautionary Observation
Move youth from Precautionary Observation to Secure Observation
Discontinue Precautionary Observation and transition youth to Close Supervision
Secure Observation
Continue Secure Observation
Move youth from Secure Observation to Precautionary Observation
Discontinue Secure Observation and transition youth to Close Supervision
NOTE: Any discontinuation of Precautionary Observation or Secure Observation requires completion of the
“Request for Discontinuation of Suicide Precautions” on page 4 of this form.
8. R
T
F
-
:
ECOMMENDATIONS FOR
REATMENT OR
OLLOW
UP
9. C
W
L
M
H
P
:
ONSULTATION
ITH
ICENSED
ENTAL
EALTH
ROFESSIONAL
10. C
F
S
/D
D
:
ONFERRED WITH
ACILITY
UPERINTENDENT
IRECTOR OR
ESIGNEE
11. N
(I
A
):
OTIFICATIONS
F
PPLICABLE
Parent/Legal Guardian
Juvenile Probation Officer (JPO)
Outside Provider
Name:___________________________
Name:_______________________
Name:_______________________
Notified by: Telephone
Letter
E-mail
Notified by: Telephone
E-mail
Notified by: Telephone
E-mail
Date: _____________ Time: _________
Date: __________ Time: _________
Date: ________ Time:________
Completed By:
Mental Health Clinical Staff Person’s Signature, Title
Date
Time
Reviewed By:
Licensed Mental Health Professional’s Signature, Title
Date
Time
Reviewed By:
Facility Superintendent/Program Director/Designee Signature
Date
Time
Rule 63N-1
MHSA 005
August 2006
Page 2 of 3
Youth’s Name
JJIS #
REQUEST FOR DISCONTINUATION OF SUICIDE PRECAUTIONS
I am requesting that this youth be:
TRANSITIONED TO NORMAL ROUTINE
Discontinued from Precautionary Observation and transitioned to Close Supervision
Discontinued from Precautionary Observation and placed on standard supervision
Discontinued from Secure Observation and transitioned to Close Supervision
Mental Health Disposition Notes:
(Document below the licensed mental health professional’s review and concurrence
with discontinuation of Suicide Precautions. Also document below any instructions or recommendations made by the licensed
mental health professional).
M
H
C
S
P
S
D
T
ENTAL
EALTH
LINICAL
TAFF
ERSON
S
IGNATURE
ATE
IME
Documentation of the licensed mental health professional’s review and concurrence with Assessment of
NOTE:
Suicide Risk findings is required prior to the youth’s removal from suicide precautions and transition to normal
routine. Documentation must clearly specify that the licensed mental health professional concurs with the youth’s
removal from suicide precautions and any instructions or recommendations made by the licensed professional.
Facility Superintendent/Program Director’s or Designee’s
Authorization to Discontinue Suicide Precautions:
YES NO
Licensed Mental Health Professional has conferred with Facility Superintendent/Program Director or Designee
Facility Superintendent/Program Director or Designee authorizes discontinuation of suicide precautions
Comments:
Facility Superintendent/Program Director or Designee Signature
Date
Time
Clinical Review
(Licensed Mental Health Professional’s Review and Comments)
Comments:
Licensed Mental Health Professional’s Signature
Date
Time
Rule 63N-1
MHSA 005
August 2006
Page 3 of 3
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