Mental Health Check Request Form

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** If you believe an ERT Member is in immediate danger of injuring themselves or others, call 9-1-1. * *

This form is to inform AmeriCorps St. Louis (ACSTL) staff that you have concerns about a Member's mental health and you do not feel comfortable having a conversation with that Member about your concerns. The form will be reviewed by ACSTL staff, and you might be contacted for clarification.

When filling out the form, be honest and objective. Give all information that you believe is relevant, such as what changes you have noticed with the Member of concern, when these changes started, dates of events, direct quotes from the Member of concern, any means of harms the Member of concern has access to, etc.

Full name of the Member of concern *

Your full name *

SUICIDALITY CHECK: Do you have reason to believe that the Member of concern in currently considering suicide? *

Yes

Have you attempted to talk to the Member of concern about their behavior in regards to suicide?

Yes

Clear selection

Has the Member of concern attempted suicide before?

They told me "YES" they have

They told me "NO," they have not

I don't know

Other

Clear selection

Has the Member of concerned talked about a plan for how they would die by suicide?

They told me they DO have a plan

They told me they DO NOT have a plan

I don't know

Other

Clear selection

Narrative section

Share any concerning information here. Here are some questions to consider: What are your main concerns? What changes have you noticed with the Member of concern, and when did these changes start? Helpful information includes: dates of events, direct quotes from the Member of concern, any means of harms the Member of concern has access to, etc.

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