BSADStudentScreeningForm_0

SOS Signs of Suicide
Student Screening Form


Brief Screen for Adolescent Depression (BSAD)*
      Please answer the following questions as honestly as possible by circling the
      “Yes” or “No” response.

      In the last four weeks...

 1.   Have you felt like nothing is fun for you and you just aren’t interested in anything?                                  Yes   No



 2. Have you had less energy than you usually do?                                                                            Yes   No



 3.   Have you felt you couldn’t do anything well or that you weren’t as good-looking or as                                  Yes   No
      smart as most other people?



 4.   Have you thought seriously about killing yourself?                                                                     Yes   No



 5.   Have you EVER, in your WHOLE LIFE, tried to kill yourself or made a suicide attempt?                                   Yes   No



 6.   Has doing even little things made you feel really tired?                                                               Yes   No



 7.   Has it seemed like you couldn’t think as clearly or as fast as usual?                                                  Yes   No



 Are you currently being treated for depression?                   Yes         No


Identifying Trusted Adults
 List a trusted adult you could turn to if you need help for yourself or a friend (example: “My English 			
 teacher,” “counselor,” “my mother,” “uncle,” etc.)
 In school       ________________________________
 Out of school ________________________________




                       This instrument is designed for screening purposes only and is not to be used as a diagnostic tool.
                   SOS Signs of Suicide - Your BSAD Score and What It Means
The BSAD (Brief Screen for Adolescent Depression) is a self-survey so you can check yourself for depression
and suicide risk. Your BSAD survey score will tell you whether you should see a school health professional
(psychologist, nurse, counselor or social worker) for a follow-up discussion.

To find out your BSAD score, add up the number of “Yes” answers to questions 1-7. Use the table below to
find out what your score means and what you should do.

    SCORE                                                                MEANING
     0-2        It is unlikely that you have depression.

                However, if you often have feelings of sadness you should talk to a trusted adult
                (parents/guardians/school staff person) to try to figure out what you should do.

                Even though your score says that you are not depressed you might still want to talk to a
                healthcare professional if your feelings of sadness do not go away.


       3        It is possible that you have depression.

                You should talk with a healthcare professional. Tell a trusted adult (parent/guardian/
                school staff person) your concerns and ask if they could help you connect with a mental
                health professional.

                If it makes you feel more comfortable, bring a friend with you. Tell the adult that you may
                be clinically depressed and that you might need to see a mental health professional.


     4-7        It is likely that you have depression.

                You probably have some significant symptoms of depression and you should talk to a
                mental health professional about these feelings. Tell a trusted adult (parent/guardian/
                school staff person) about your feelings and ask if they could help you see a mental health
                professional.




  Questions     These two questions are about suicidal thoughts and behaviors. If you answered “Yes” to
   4 and 5      either question 4 or 5, you should see a mental health professional immediately -
                regardless of your total BSAD score.


Identifying Trusted Adults
 Concerned      It’s important to know who you can turn to if you need to talk. If you had trouble identifying
   about        a trusted adult, ask to speak with the person implementing the SOS program. Let someone
 yourself or    know you need help building this important connection. If you are worried about your friend
  a friend?     but your friend refuses to speak to someone, ask your trusted adult to help get your friend
                the assistance he or she needs.



Bottom line: Take these screening results seriously and get help. You or your friend deserves to feel better,
and help and support are available to you. If you are worried about yourself or someone else, call the Na-
tional Suicide Prevention Lifeline, at 1-800-273-TALK (8255). Crisis Text Line Text ‘ACT’ to 741741 for free,
24/7 crisis support in the U.S.


                    This instrument is designed for screening purposes only and is not to be used as a diagnostic tool.