ACS Social Emotional Learning (SEL) and School Mental Health (SMH) Improvement Plan 2022

Arapahoe Charter School Social Emotional Learning (SEL) and School Mental Health (SMH) Improvement Plan

(per NC SBOE Policy SHLT-003) Adopted June 24, 2021 Updated July 2022

Contents INTRODUCTION ........................................................................................... 3 SCOPE OF THE SCHOOL MENTAL HEALTH IMPROVEMENT PLAN ....... 3 AIMS OF THE SCHOOL MENTAL HEALTH IMPROVEMENT PLAN ...... 3 STUDENT SERVICES SUPPORT TEAM ..................................................... 4 TEACHING ABOUT MENTAL HEALTH ........................................................ 5 SUPPORT AT SCHOOL AND IN THE LOCAL COMMUNITY .................. 5 NOTIFICATION OF SERVICES .................................................................... 7 STAFF PROFESSIONAL DEVELOPMENT ............................................... 7 STAFF WELL-BEING .................................................................................... 8 THREAT ASSESSMENT AND SUICIDE RISK PROTOCOL ........................ 8 MANAGING DISCLOSURES ........................................................................ 8 WHOLE SCHOOL APPROACH TO STUDENT MENTAL HEALTH .............. 9 ANNUAL PLAN REVIEW............................................................................... 9 APPENDICES ............................................................................................. 10 A. The CASEL Framework ........................................................................... 11 B. Counseling Referral Form ........................................................................ 13 C. Sample Memorandum of Understanding for Mental Health Agencies ...... 14 D. Mental Health Training Calendar 2021-22................................................ 18 E. Suicide/Threat Risk Assessment Screening Form.................................... 19 F. DISCLOSURE RECORD FORM .............................................................. 28 G. Resources ............................................................................................... 29

INTRODUCTION At Arapahoe Charter School, we are committed to supporting the mental health and wellbeing of our students and staff. We understand that the social and emotional needs of our students are an important component of the learning process. According to the CASEL (Collaborative for Academic, Social and Emotional Learning) framework, “social and emotion learning (SEL) is an integral part of education and human development. SEL is the process through which all young people and adults acquire and apply the knowledge, skills, and attitudes to develop healthy identities, manage emotions and achieve personal and collective goals, feel and show empathy for others, establish and maintain supportive relationships, and make responsible and caring decisions” (https://casel.org/what-is-sel/). See Appendix A: The CASEL FRAMEWORK. In direct relationship to CASEL’s framework, we have five core values that we utilize to promote a healthy and supportive culture in our school. These core values are: • • • • •

Energize your community Respect yourself and others Dream fearlessly Achieve greatness Share your brilliance

At Arapahoe Charter School our culture is supportive, caring, and respectful. We encourage students to be open and we want each student to have their voice heard.

We also understand that there are daily life challenges that each of us face and that some of us may need assistance to cope with these challenges. While positive mental health is everybody’s responsibility, we have specific steps in place for those who need additional emotional support.

SCOPE OF THE SCHOOL MENTAL HEALTH IMPROVEMENT PLAN This School Mental Health Improvement Plan is a guide to all stakeholders. It outlines our approach to promoting positive mental health and wellbeing for our staff and students.

AIMS OF THE SCHOOL MENTAL HEALTH IMPROVEMENT PLAN The aim of our plan is to demonstrate our commitment to the mental health of our staff and students.

At Arapahoe, we will: • • • • •

Help our students understand their emotions.

Ensure our students feel comfortable sharing their concerns and worries.

Help our students form and maintain healthy relationships.

Encourage our students to be confident and help promote their self-esteem.

Help our students develop resilience and coping skills.

We will promote a healthy environment by: • • • • • • • • • • •

Promoting positive mental health and emotional wellbeing in all staff and students.

Celebrating academic and non-academic achievement.

Promoting our school’s core values and encouraging a sense of belonging and community.

Providing opportunities to develop a sense of worth.

Promoting our students’ voices and giving them opportunities to participate in decision making.

Celebrating our students for who they are.

Making all students feel valued and respected.

Adopting a whole school approach to mental health and providing support to any student who needs it.

Raising awareness among staff, students, parents and the community about mental health issues and their signs and symptoms.

Enabling staff to respond to early warning signs of mental health issues in students.

Supporting staff who are struggling with mental health issues.

STUDENT SERVICES SUPPORT TEAM All staff members have a responsibility to promote the mental health of students and each other. However, certain staff members have a specific role in the process. Our Student Support Services Team members include: Macy Poole, K-8 School Counselor Shari Sias, K-8 School Counselor Sherry Reeves, 9-12 School Counselor Tiffany Bennett, School Nurse Greg Rohrman, Data Manager Julie Edwards, Administrator Lori Andrews, MTSS Chairperson Partner Mental Health Agency personnel Arapahoe Charter’s Student Support Services Team will provide mental health screening, assessment and services that promote and support positive social, emotional, and behavioral skills and wellness in all students. Services include: •

Universal mental health screening

•

SEL activities

•

School climate activities

•

Positive behavior management and classroom management

•

Bullying prevention

•

Restorative discipline practices

•

Mental health literacy for all stakeholders

If a staff member is concerned about the general mental health and wellbeing of a student, then a referral should be made to a member of the Student Support Team. In the event of a mental health emergency (i.e., suicide threat), a Student Support Team member should be contacted immediately. See Appendix B for Counseling Referral Form.

TEACHING ABOUT MENTAL HEALTH The North Carolina Essential Standards for Health Education has a robust Mental and Emotional Health component for students in grades K - 9. These standards are designed to teach students the skills, knowledge and understanding they need in order to be mentally healthy. Standards are introduced based on the students’ developmental level, with the standards becoming increasingly complex as the students age. Topics covered include feelings, coping skills, stress management, responsibility, peer influence, effective communication, risky behaviors, mental illness, and so on.

In addition to addressing mental and emotional health through the Health Education curriculum, these standards are also intertwined in our English and Social Studies curriculum. It is our aim to immerse our students with social and emotional learning throughout the school day so that they are provided with strategies to keep them mentally healthy.

SUPPORT AT SCHOOL AND IN THE LOCAL COMMUNITY At Arapahoe Charter we have a range of support available in school for students who are struggling. These supports are: •

Discussion of social, emotional, and behavioral needs of any student referred to the MTSS (multi-tiered support system) team; the aim of the MTSS referral is to determine how to better serve the at-risk student by providing additional supports.

•

Individual student counseling with School Counselor; the aim of individual student counseling is to help a student who is struggling with a temporary mental health issue. o This support can be accessed by student/teacher/parent referral. o There is a link to the “School Counselor Referral” form on the school website. o At the beginning of the school year, the School Counselors visit the classrooms to introduce themselves and to explain to students their roles in assisting them.

Small group counseling; the aim of small group counseling is to help a group of students who are struggling with a particular social/emotional issue. o This support can be accessed through teacher or parent referral. o School Counselors make teachers aware of the availability of group services.

•

•

Classroom guidance; the aim of classroom guidance is to expose students to the guidance curriculum which promotes the knowledge, attitudes and skills necessary for academic, social and personal growth.

There are also support networks available for our students and their families in our local community. Community support services that partner with Arapahoe Charter School include: •

•

•

•

•

Still Waters o Still Waters is a nonprofit, mental health program of Heart Works that serves children, teens, adults, couples, and families. o The goal is to provide mental health counseling for a variety of issues (anxiety, stress, grief, depression, low self-esteem, bullying, self-harm, substance abuse, lack of focus/hyperactivity, family dysfunction, PTSD, oppositional and defiant behaviors, etc.) o Still Waters referrals can be made directly via their website or by school personnel.

RHA Health Services/New Bern, NC o RHA Health Services provides comprehensive behavioral health supports including mental health support services and substance use services. o The goal is to provide mental health counseling for a variety of behavioral health and substance abuse issues. o Same day access is available on a walk-in basis on Mondays and Tuesdays, 8:00-12:00. o Mobile Crisis Management is available 24/7/365. Call 1-844-709-4097 for RHA MCM EAST. Pamlico Family and Child Therapy o Pamlico Family and Child Therapy provides therapeutic outpatient services for children, adults, and families. o The goal is to provide individualized therapy that supports and guides one through challenging situations and life crises. o Referrals can be made by calling 252-745-7401 or emailing pamlicocft@gmail.com.

Pamlico Partnership for Children o Pamlico Partnership for Children is a nonprofit organization that strives to bring together the whole community, as well as parents, teachers, and childcare providers to create positive change for children. o PPFC provides programs and services for the youngest citizens of Pamlico County, supports the providers of high-quality childcare, serves as a community resource, and is a supporter of a growing effort to provide assistance to the families and children living in our community. o Services can be accessed by calling 252-745-7850.

Promise Place o Promise Place is a nonprofit organization that serves victims of sexual assault, crime, and/or trauma.

o

o

The goal of Promise Place is to provide advocacy, community outreach, trauma therapy and prevention education related to crimes and trauma involving sexual assault.

The Crisis Line is available 24/7 at 252-635-7096. Services can also be accessed Monday-Friday by calling 252-636-3381.

A Memorandum of Understanding (MOU) for each of these entities is on file. A sample MOU can be found in Appendix C. NOTIFICATION OF SERVICES Our School Mental Health Improvement Plan is published in our Student Handbook and Staff Handbook, both of which are accessible on our website.

STAFF PROFESSIONAL DEVELOPMENT A provision of our School Mental Health Improvement Plan is that we provide mental health training to all school personnel who work with students in any capacity. In year one [2021-22] six hours of staff training was provided. In subsequent years, a minimum of two hours of training will be provided. Training topics include: o Youth mental health o Definition o National and State Statistics o Suicide prevention o Myths and Facts o Risk Factors o Protective Factors o Warning Signs o Resources o Substance abuse o Teenage dating violence o Child sexual abuse prevention o Sex trafficking prevention (every 2 years on even-numbered years) o Child sexual abuse and human trafficking prevention o Best practices from the field of prevention o The grooming process of sexual predators o The warning signs of sexual abuse and sex trafficking o How to intervene when sexual abuse or sex trafficking is suspected/disclosed o Legal responsibilities for reporting sexual abuse/sex trafficking o Available resources for assistance A copy of the annual mental health training calendar can be found in Appendix D.

STAFF WELL-BEING School staff members are often so busy taking care of students that they forget to take care of themselves. We realize that if we don't promote healthy practices and activities for our staff, then they will not have optimal effectiveness as professionals. We encourage all staff to monitor their emotional and physical health and to practice sound wellness. Also, we encourage all staff to seek mental health support when needed.

In order to promote the health of staff, Arapahoe Charter will provide wellness activities to staff during the school year. These activities will vary based on staff interest but will include activities to promote a healthy diet, physical activity, mental well-being and staff bonding.

THREAT ASSESSMENT AND SUICIDE RISK PROTOCOL A student is considered at risk for suicide when any peer, teacher or other school employee identifies him/her as potentially suicidal because he/she has directly or indirectly expressed a suicidal thought or has demonstrated any of the warning signs. A School Counselor or School Social Worker should be notified immediately.

If a Counselor or Social Worker is unavailable, one of the following staff members should be notified: • School Administrator • School Resource Officer • School Nurse • School Discipline Coordinator At no time during the screening process should a student at-risk for suicide be left alone. If imminent danger exists, 911 or RHA’s Mobile Crisis Unit will be called.

Once the student is secure with the Student Support Services Team member, then the SSST member will complete the Suicide/Threat Risk Screening process and a parent/guardian will be notified immediately.

Any student who has been screened for suicide risk shall not be permitted to return to school until a Threat Assessment has been completed by a physician or mental health worker. See Appendix E for the Suicide/Threat Risk Screening form.

MANAGING DISCLOSURES If a student discloses concerns about him/herself or a friend, to any member of staff, then staff will respond in a calm, supportive, and non-judgmental manner. Disclosures will be recorded confidentially and kept on file with the School Counselor. Disclosures will only be shared with the appropriate authorities if it is necessary to keep the child safe. The disclosure record will document: • • •

The date of the disclosure.

The name of the staff member to whom the disclosure was made.

The nature of the disclosure.

•

Agreed next steps.

See Appendix F for a Disclosure Record Form.

CONFIDENTIALITY If a staff member thinks it is necessary to share concerns about a student, the student shall be informed: • • •

With whom the information will be shared.

What information will be shared.

Why it is necessary to share the information.

WHOLE SCHOOL APPROACH TO STUDENT MENTAL HEALTH Arapahoe Charter School takes a “whole school” approach towards the mental health of our students. This means working with parents/guardians and with other agencies and partners, when necessary.

We aim to support parents as much as possible. This means keeping them informed about their child’s well-being. To support parents, we will: • • • • •

Share sources of information and support about mental health and emotional wellbeing.

Ensure that parents are aware of who to talk to if they have any concerns about their child.

Give parents guidance about how they can support their child’s/children’s positive mental health.

Ensure this plan is easily accessible to parents.

Keep parents informed about the mental health training our school staff receive and how mental health is covered in our school curriculum.

In addition, as part of our whole school approach, we will also work with other agencies to support our students’ emotional health and well-being. This might include liaising with: • • • •

Pediatricians/Health Clinics Community Counseling Services Community Therapists Department of Social Services

ANNUAL PLAN REVIEW This plan will be reviewed annually so that it remains up to date, useful, and relevant. Data from services provided and referrals made throughout the school year will inform revisions. We will also regularly review the plan in accordance with local and state policy changes.

Furthermore, we will complete an annual School Mental Health survey of staff, students, and parents to determine each stakeholders’ level of understanding of the Mental Health plan.

APPENDICES

A. The CASEL Framework

CASEL’s Framework for Systemic Social and Emotional Learning

Overview CASEL’s Framework for Systemic Social and Emotional Learning is an integrated framework that highlights five SEL competencies promoted through multiple contexts. Social and emotional learning (SEL) is the process through which children and adults develop the skills, knowledge, and attitudes necessary to understand and manage emotions, set and achieve positive goals, feel and show empathy for others, establish and maintain positive relationships, and make responsible decisions. To frame thinking, the Collaborative for Academic, Social, and Emotional Learning (CASEL) has identified five core social and emotional competence clusters to use in interventions: self-awareness, self-management, social awareness, relationship skills, and responsible decision-making. Below, we identify and define the competencies as they are presented in the framework.

Self-awareness: The ability to accurately recognize one’s emotions and thoughts and their influence on behavior. The ability to accurately assess one’s strengths and limitations and possess a well-grounded sense of confidence and optimism.

• This includes: recognizing one’s emotions and thoughts; assessing one’s strengths and limitations; confidence; self-efficacy/growth mindset Self-management: The ability to regulate one’s emotions, thoughts, and behaviors effectively in different situations. This includes managing stress, controlling impulses, motivating oneself, and setting and working toward achieving personal and academic goals.

• This includes: self-regulation; stress management; impulse control; setting and working toward achieving personal and academic goals; motivation; organizational skills Social-awareness: The ability to take the perspective of and empathize with others from diverse backgrounds and cultures, to understand social and ethical norms for behavior, and to recognize family, school, and community resources and supports.

• This includes: taking the perspective of others from diverse backgrounds and cultures; empathy; understanding social and ethical norms for behavior; recognizing family, school, community resources, and supports Relationship skills: The ability to establish and maintain healthy and rewarding relationships with diverse individuals and groups. This includes communicating clearly, listening actively, cooperating, resisting inappropriate social pressure, negotiating conflict constructively, and seeking and offering help when needed.

• This includes: clear communication; active listening; cooperation/teamwork; resisting inappropriate social pressure; negotiating conflict; seeking and offering help; establishing and maintaining relationships Responsible decision-making: The ability to make constructive and respectful choices about personal behavior and social interactions based on consideration of ethical standards, safety concerns, social norms, the realistic evaluation of consequences of various actions, and the well-being of self and others.

• This includes: identifying problems; analyzing situations; solving problems; evaluation, reflection, awareness of ethical responsibility

B. Counseling Referral Form

School Counseling Referral Form

Student Name: _______________________________________________________ Grade: _____________ Teacher: _______________________________________ Referring Individual: ___________________ Relationship to Student_____________ Date of Referral: ______________________ Indicate reason for referral: (Check all that apply) Academic Concerns ⃞ Attendance ⃞ Underachievement ⃞ Homework ⃞ Study Skills ⃞ Organization ⃞ Goal Setting ⃞ Other___________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________

Personal/Social-Emotional Concerns ⃞ Anger management

⃞ Social Skills

⃞ Bullying

⃞ Depression

⃞ Anxiety

⃞ Withdrawnness

⃞ Attitude

⃞ Adjustment issues ⃞ Personal hygiene

⃞ Honesty

⃞ Self-esteem ⃞ Defiance

⃞ Family issues

⃞ Health concerns ⃞ Theft/Vandalism

⃞ Other_____________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________

************************************************************************

Counselor’s Notes: ___________________________________________________________________

_____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________

C. Sample Memorandum of Understanding for Mental Health Agencies Memorandum of Understanding between Arapahoe Charter School and [Community Mental Health Agency]

The Parties of this Memorandum of Understanding (MOU) are Arapahoe Charter School and [Mental Health Agency], hereinafter collectively referred to as the Parties.

Purpose: The purpose of this agreement is to establish roles and responsibilities of the Parties to develop and implement a comprehensive school mental health plan that utilizes the strengths and expertise of school and community-partnered professionals. The comprehensive school mental health plan details the partnership between Arapahoe Charter School and community mental health agencies in an effort to provide a multi-tiered system of mental health supports (MTSS) to support students, families, and the school community. Mental health services include activities, services, and supports that address social, emotional, and behavioral well-being of students, including substance use.

Roles and Responsibilities: The Parties agree to the following roles and responsibilities.

Responsibilities of [Mental Health Agency]: 1. Actively participate in school’s Student Support Services team to support effective school- community collaboration that promotes: o well-defined roles and responsibilities of team members (with structures in o o o o o

place to avoid duplication of efforts), data sharing, data-based decision making, seamless services and supports across tiers, integration of mental health and other academic supports effective referral processes

2. Provide mental health screening, assessment, and services for a) students who have been identified through needs assessments and school teaming processes as being at risk for a given concern or problem, or b) students who display a particular mental health concern or problem and display significant functional impairment. Identified students must have written parental permission to receive mental health services from the agency. Potential services may include: o o o o o

Progress monitoring of identified students Social skills training/coaching Individualized treatment for specific mental health issue(s) Teacher/staff consultation Family therapy to support referred students

3. Utilize evidence-based services and supports,* as available. When evidence-based interventions are not available for intended population, selected interventions should be based on promising/best practices and should be evaluated for program impact. *Evidence-Based Services and Supports are programs, services, or supports that are

based directly on scientific evidence, have been evaluated in large-scale studies, and have been shown to reduce symptoms and/or improve functioning. For instance, evidence-based services and supports are recognized in national evidence-

based registries, such as the Substance Abuse and Mental Health Services Administration (SAMHSA), National Registry of Evidence-based Programs and Practices (NREPP), Blueprints for Healthy Youth Development, and Institute of Education Sciences (IES) What Works Clearinghouse (WWC). o o o o

Collect and report data that documents: Clinician productivity Program and intervention impact on student/school psychosocial and academic functioning Student/family satisfaction and engagement

4. Ensure the complete confidentiality of any and all identifying student and family information gathered in the performance of this agreement. The information gathered, used, and developed shall not be provided to any other party without the express written approval of individual(s) authorized to give consent for release of information.

5. Meet federal, state, and local regulations required of community mental health providers, including those stipulated by the Health Insurance Portability and Accountability Act (HIPAA).

Responsibilities of Arapahoe Charter School: 1. Demonstrate a commitment to hosting the community mental health agency within the school to support a multi-tiered system of mental health support (MTSS) for students.

2. Identify a school point of contact to facilitate successful integration of the community mental health agency into the school, and to address any concerns.

3. Provide confidential space in the school that includes access to a locked file cabinet and mechanism for communicating with families and other providers (e.g., phone, computer, internet access).

4. Facilitate inclusion and active participation of community mental health agency in the school mental health team. To this end, school and mental health agency should: o Define roles and responsibilities to avoid duplication of efforts o Understand and support each other’s purpose and work o Have a process/procedure to ensure frequent and consistent communication o Address any confidentiality barriers to facilitate regular information sharing 5. Create data-based decision models and referral processes that promote early identification and intervention for students.

Mental Health Agency as an Independent Contractor: In providing services to Arapahoe Charter School students, [Mental Health Agency] shall at all times operate as an independent contractor and shall have no authority to make any arrangements or incur any liabilities on behalf of the Board.

Duration and Termination: This Agreement is for the period beginning Month/Day/Year to Month/Day/Year. Either party may terminate this Agreement for non-performance after first giving written notice of breach to the other party and an opportunity for the other party to cure the non-performance within fifteen (15) days of the receipt of written notice. Notice shall be deemed effective when

delivered via certified mail to the following: Arapahoe Charter School 9005 NC Hwy 306 South Arapahoe, NC 28510 And to [Mental Health Agency] Address City, State, Zip Insurance and indemnification: [Mental Health Agency] shall purchase and maintain during the term of any resulting agreement: Commercial General Liability Insurance of at least $5,000,000 combined single limit coverage written on an occurrence basis covering all premises and operations, and including Personal Injury, Independent Contractor, Contractual Liability, and Products and Completed Operations. The Board of Education of Arapahoe Charter School and all of its agents and employees shall be names as an additional insured, which must be shown on insurance certificates furnished to Arapahoe Charter School.

Workers' Compensation Insurance benefits as required by North Carolina law to include Employers’ Liability coverage with limits of at least $100,000 each accident, $100,000 each employee disease, and $500,000 disease policy limit.

Professional Liability Insurance with limits of at least $1,000,000 each occurrence and $3,000,000 aggregate.

[Mental Health Agency] shall indemnify and hold harmless the Board, its employees, servants, and agents against all liabilities, loss, charges, and expenses, including court costs and attorney’s fees, resulting from the failure of [Mental Health Agency], its employees, servants, and agents, to faithfully and competently perform its obligations hereunder or arising from or caused by [Mental Health Agency]’s provision of services.

Whole Agreement: This MOU contains the entire agreement between the parties with respect to the subject matter set forth herein, but may be modified with the written consent of both parties.

IN WITNESS WHEREOF, the parties have caused this Agreement to be executed by their authorized representatives.

By: Executive Director Arapahoe Charter School By: Executive Director Community Mental Health Agency

D. Mental Health Training Calendar 2022-23

ARAPAHOE CHARTER SCHOOL MENTAL HEALTH TRAINING CALENDAR FOR 2021-22

TRAINING TOPIC(S) Youth Mental Health • Definition • National and State Statistics Suicide Prevention • Myths and Facts • Risk Factors • Protective Factors • Warning Signs • Resources Substance Abuse Teenage Dating Violence Child Sexual Abuse Prevention Sex Trafficking  Child sexual abuse & human trafficking prevention  Best practices from the field of prevention  The grooming process of sexual predators  The warning signs of sexual abuse and sex trafficking  How to intervene when sexual abuse or sex trafficking is suspected or disclosed  Legal responsibilities for reporting sexual abuse/sex trafficking  Available resources for assistance

DATE OF TRAINING August 8, 2022

DURATION

TRAINERS

1 hour

Members of Student Services Support Team

Mandatory Teacher Workday TBD

1 hour

Members of Student Services Support Team

By December 20, 2022

2 hours

TBD

(Training to be repeated every 2 years)

E. Suicide/Threat Risk Assessment Screening Form

Arapahoe Charter School

Student Suicide/Threat Risk Assessment Date: ___________________________

Time: __________________________

DOB: ___________________________

Age: ___________________________

Gender: _________________________

Address: ____________________________________________________________

Cell Phone: ______________________

Student’s Name: ____________________________________________________ Parent’s Name: _____________________________________________________ ____________________________________________________________

Home Phone: ___________________

REASON FOR REFERRAL: (Provide specific details)

______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ Person making referral: ______________________________________

Title: _________________________________

Arapahoe Charter School Student Suicide/Threat Risk Assessment This form is to be completed by a medical doctor or licensed mental health professional and returned to the school.

ASSESSMENT INFORMATION Person conducting assessment: _______________________________________________________________________

Agency: __________________________________________________________________________________________________ Profession / Position: __________________________________________________________________________________

Person accompanying student to assessment: _______________________________________________________ STRESSORS: Is the student experiencing severe psychological distress?

Yes

No

Does the student have frequent thoughts of self-harm or suicide?

Yes

No

Has the student made verbal threats of suicide?

Yes

No

Have there been major changes in recent behavior along with negative feelings and thoughts? (Such changes may be related to a recent loss or threat of loss of significant others; loss of status or opportunity; sexual or physical abuse, substance abuse, family problems, academic failure, legal or financial problems, etc.)

Yes

No

PAST ATTEMPTS AND CURRENT PLANS:

Have there been suicide attempts by the student or significant others in his or her life?

Does the student have a detailed, feasible plan with access to means?

Has the student made special arrangements such as giving away valued possessions?

Does the student fantasize about suicide as a way to make others feel guilty or as a way to a better life?

Yes Yes Yes Yes

No No No No

Does the student have frequent thoughts about harming others?

Yes

No

Has the student made recent threats of harm toward others?

Yes

No

Has the student behaved in violent ways towards others in the past?

Does the student have a detailed, feasible plan for harming others and access to means?

Does the student see violence toward others as a way of solving a problem?

Yes Yes

SUPPORT SYSTEM:

Yes

Are family members available to support the student in the period of stress?

Yes

Has professional support been available to the student in the period of stress?

CONCLUSIONS:

Yes

No No No No No

Based on my assessment, the student’s current stressors, past attempts, current plans and available support, it is my opinion that the student’s current risk level for suicide or other self-harm is: Based on my assessment, the student’s current stressors, past attempts, current plans and available support, it is my opinion that the student’s current risk level for violence or harm to others is:

High Medium Low High Medium Low

Based on my assessment, the student’s current stressors, past attempts, current plans and available support, it is my opinion that the student may return to school on:

TREATMENT PLAN

Recommendations for school personnel:

______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ Agency’s recommendations for treatment:

______________________________________________________________________________________________________________

______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________

______________________________________________________________________________________________________________ ___________________________________________________ Signature of person conducting assessment

___________________________________________________ Title

___________________________________________________ Date

___________________________________________

Printed name of person conducting assessment

ARAPAHOE CHARTER SCHOOL PARENTAL NOTIFICATION OF SUICIDE or SELF-HARM ATTEMPT / THREAT Student’s Name:

________________________________________________________________

Gender:

________________________________________________________________

Date of Birth: Grade:

Homeroom Teacher: Parent Name: Address:

Telephone: •

• •

________________________________________________________________ ________________________________________________________________ ________________________________________________________________

________________________________________________________________

________________________________________________________________ ________________________________________________________________ ________________________________________________________________ Home ________________________

Cell ________________________

As parent / guardian or responsible party, I have been informed by school personnel that ______________________________________________ has threatened / attempted suicide or self-harm or harm to others and is in need of immediate treatment by a trained professional.

I have been made aware of the need to provide adequate supervision of my child while he/ she is out of school.

I understand that in order for my child to return to school he/ she must : o Be accompanied by a parent / guardian or responsible party; o Bring an Authorization For Re-Entry form that is completed and signed by an assessment clinician; o See a counselor/ principal or designee to complete the re-entry process.

Signature: ___________________________________________

Relationship: _________________________________

Title: _______________________________________________

Telephone: ___________________________________

School Personnel Signature: _____________________________________________________________________________

ARAPAHOE CHARTER SCHOOL AUTHORIZATION FOR RE-ENTRY (Suicide/ Threat / Self Harm / Attempt) Date: ___________________________

Time: __________________________

DOB: ___________________________

Age: ___________________________

Gender: _________________________

Address: ____________________________________________________________

Cell Phone: ______________________

Student’s Name: ____________________________________________________ Parent’s Name: _____________________________________________________ ____________________________________________________________

Home Phone: ___________________

Person accompanying student to assessment: _________________________________________________________

Relationship to student: __________________________________________________________________________________ Child’s current status relative to inflicting self-harm or harm to others:

______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________

Medication given: _________________________________________________________________________________________

Possible side effects: ______________________________________________________________________________________ Agency follow-up plan: ___________________________________________________________________________________ Date student is able to return to school: ________________________________________________________________

Level of threat: ____________________________________________________________________________________________ Recommended plan as related to school personnel’s role: (Must address level of threat)

______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________

Next scheduled appointment: ____________________________________________________________________________ Assessment clinician signature: __________________________________________ Date: ________________________ Assessment clinician printed name: ______________________________________Date: ________________________ Position: ________________________________________________ Agency: ________________________________________ ** Please attach discharge summary or notes that may help the school assist this child. ** Received by: ____________________________________________ Date:__________________________ (School Personnel)

ARAPAHOE CHARTER SCHOOL NOTICE OF PARENTAL REFUSAL (Suicide Threat - Self Harm / Assessment) Student’s Name:

________________________________________________________________________

A. PARENT’S REFUSAL TO SEEK ASSESSMENT As a parent / guardian or responsible party, I have been informed by school personnel that the above named student, for whom I am responsible, has threatened or demonstrated harm to self or others and is in need of immediate assessment by a trained professional. Having been informed by school personnel of this situation, I refuse to seek the immediate assessment needed for the above-named child. I understand that the school will follow school board policy and will file a Child Neglect report with the Pamlico County Department of Social Services (DSS). _______________________________________________________

_______________________________

(Witness)

(Date)

(Signature of Parent)

_______________________________________________________

(Date)

_______________________________

The parent / guardian or responsible party refused to sign the above statement concerning assessment. _______________________________________________________

_______________________________

(Witness)

(Date)

(School Representative)

_______________________________________________________

(Date)

_______________________________

Called DSS: Date: ___________________ Time: _________________ Contact Person: _____________________ * NOTE: School personnel are to complete the DSS Notification Form B. PARENT’S REFUSAL TO COME TO SCHOOL The parent / guardian or responsible party refused to come to school after being informed of their child’s suicide / self-harm threat or attempt. The child is named above. _______________________________________________________

_______________________________

(Witness)

(Date)

(School Representative)

_______________________________________________________

(Date)

_______________________________

Called DSS: Date: ___________________ Time: _________________ Contact Person: _____________________ * NOTE: School personnel are to complete the DSS Notification Form

ARAPAHOE CHARTER SCHOOL NOTICE OF PARENT REFUSAL (continued) Student’s Name:

________________________________________________________________________

C. PARENT’S REFUSAL TO FOLLOW GUIDELINES FOR RE-ENTRY TO SCHOOL The parent / guardian or responsible party did not follow the guidelines for their child’s reentry into school as stated in the PARENTAL NOTIFICATION OF SUICIDE or SELF-HARM ATTEMPT / THREAT. The child is named above. _______________________________________________________

_______________________________

(Witness)

(Date)

(School Representative)

_______________________________________________________

(Date)

_______________________________

Called DSS: Date: ___________________ Time: _________________ Contact Person: _____________________ * NOTE: School personnel are to complete the DSS Notification Form

ARAPAHOE CHARTER SCHOOL DEPARTMENT OF SOCIAL SERVICES NOTIFICATION If abuse or neglect is suspected in a student who is contemplating or has attempted suicide or self-harm, immediately contact the Pamlico Department of Social Services (252-745-4086) and report the following information: Child’s Name: _______________________________________________________________________________ Parent / Guardian’s Name: ________________________________________________________________ Address:

_____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________

Phone Number(s):

____________________________________________________________________ ____________________________________________________________________

Specific details of the reported abusive behavior, neglect, or incident: ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ Recent changes in school attendance, performance, or behavior: ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ Date of Contact: ____________________________________________________

Time of Call: ________________________________________________________

Caseworker Contacted: ____________________________________________

Response Plan Agreed Upon: ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ Required Follow-up:

______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ The child must be kept safe and secure until a Social Worker, Child protective Services Worker, or other authorized individual accepts responsibility for the safety of the child.

ARAPAHOE CHARTER SCHOOL RELEASE OF CHILD The child must be kept safe and secure until a Social Worker, Child Protective Services Worker, or other authorized individual accepts responsibility for the safety of the child.

Child’s Name: _______________________________________________________________________________ Declaration of Responsibility: [To be signed by the Social Worker, Child Protective Services Worker, or other authorized individual accepting responsibility for the safety of the child.]

I, _________________________________________________, representing ___________________________________________ (Printed Name)

(Agency)

do hereby take custody and accept responsibility for the above named child. _____________________________________________ (Signature)

_______________________ (Date)

_____________________ (Time)

Agency Representing: _____________________________________________________________________________________ Contact Phone Number: __________________________________________________________________________________

Identification Presented: _________________________________________________________________________________

F. DISCLOSURE RECORD FORM

ARAPAHOE CHARTER SCHOOL DISCLOSURE RECORD FORM

Date of Disclosure: _________________________ Name of Student making Disclosure: ____________________________________________ Individual to whom disclosure was made: ________________________________________ Nature of Disclosure: ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________

Next Steps: ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ Signature of School Counselor __________________________________________________ Date _______________________________

G. Resources

Social-Emotional Learning Model - https://casel.org/what-is-sel/ The MHTTC National School Mental Health Curriculum - https://mhttcnetwork.org/nowavailable-school-mental-health-curriculum School Mental Health Referral Pathways (SMHRP) Toolkit https://www.escneo.org/Downloads/NITT%20SMHRP%20Toolkit_11%2019%2015%20FINA L.PDF The School Health and Performance Evaluation System (SHAPE) – Provides resources for:  A wide variety of mental health issues/topics  Screening and Assessment forms  Trauma Responsiveness Youth Mental Health First Aid – mentalhealthfirstaid.org CAMH (Centre for Mental Health and Addictions) - this site offers an integrated set of web based resources for teachers, schools and allied partners to utilize in their prevention/health promotion work with youth.

COPMI (Children of Parents with Mental Illnesses) – This site based in Australia has a wealth of resources for educators and parents.

National Institute for Mental Health (NIMH) – The NIMH website contains up-to date and reliable information about a wide range of issues relating to mental health and illness across the lifespan. It provides comprehensive information about most neuropsychiatric disorders.

Brains Beyond Borders: Healthy Mind Healthy Body – Mental health curriculum supplements designed for elementary classroom delivery in order to fill a recognized gap that currently exists in mental health materials to help teachers introduce age appropriate mental health concepts gradually over the years.

Suicide Prevention Lifeline – 1-800-273-8255 / text TALK to the Crisis Text Line – 741741 Professional Quality of Life Scale (PROQOL): measures Compassion Satisfaction and Compassion Fatigue - https://www.macmh.org/wpcontent/uploads/2016/05/Wkshp22_handout.pdf