Middle Level Suicide Awareness Questionnaire


MPS CARES SURVEY

Name ______________________________

The MPS CARES (Counselors Always Reaching Every Student) Survey will help counselors provide assistance to students who have been impacted by suicide and/or depression. This survey should be completed by Millard Public Schools students after they have completed the Awareness Lessons by school counselors.

1

Yes   No

In the past 4 weeks, I  have had thoughts of suicide.

2

Yes   No

In the past 4 weeks, I have felt depressed; a feeling of prolonged sadness that won’t go away.

3.

Yes   No

In the past 4 weeks, I have had concerns about another student having suicidal thoughts or behaviors.


If yes, Who? _____________________________ School ______________________

4

Yes   No

In the past 4 weeks, I have been concerned about another student who is feeling depressed; a feeling of prolonged sadness that won't go away.


If yes, Who? _____________________________ School ______________________

5

Yes  No

I would like to talk to a school counselor about suicide or depression.

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