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MIRECC Order Form

Together with Veterans MIRECC Order Form

Risk ID MIRECC Order Form

Proactive Outreach Form

Hello and thank you for your interest in resources either developed or distributed by the Rocky Mountain MIRECC for Suicide Prevention. Please fill out the contact and shipping info completely and accurately, including floor, room number, or any other information that will help ensure the materials reach you safely.

Please note some order limits have changed. If you will be utilizing materials for an event, or distribute to others and need larger quantities, please contact:

melissa.mcharg@va.gov

p: 720-723-6484.

Hello and thank you for your interest in resources either developed or distributed by the Rocky Mountain MIRECC for Suicide Prevention. Please fill out the contact and shipping info completely and accurately, including floor, room number, or any other information that will help ensure the materials reach you safely. Please note that the Risk ID Screener badges are intended for VA internal use only.

Please note some order limits have changed. If you will be utilizing materials for an event, or distribute to others and need larger quantities, please contact:

melissa.mcharg@va.gov

p: 720-723-6484.

This order form is for Together With Veterans community sites only. If you are not associated with a Together With Veterans site, please use the public order form site here: https://varedcap.rcp.vaec.va.gov/redcap/surveys/?s=LDW8K4W9HEEL93E3

NOTE: Together with Veterans will no longer be using a point system for orders. Please refer to product limits per each product and do not exceed total for that item.

Purchase order limits are a part of our program costs and are subject to change.

Pictures provided are examples and actual products may vary slightly.

Please note some order limits have changed as we begin to replenish stock. Please order what you anticipate utilizing in the near future. We will to try to accommodate larger orders as-needed. If you will be utilizing materials for an event, or distribute to others and need larger quantities, please contact:

Joanna.Sells@va.gov

p: 415-205-7776.

Upon graduation from the program, communities can implement one or more of the following options:

1) Use materials they have developed and funded

2) Make use of materials that are nationally available: https://varedcap.rcp.vaec.va.gov/redcap/surveys/?s=LDW8K4W9HEEL93E3

There are downloadable brochures and posters available for distribution on various topics at the following links:

Outreach & Events | Outreach Materials | Veterans Affairs (va.gov)

Outreach Posters - Women Veterans Health Care (va.gov)

Ready-To-Use VA Mental Health Materials | Spread the Word - Mental Health

3) Work with their local VA Community Engagement and Partnership Coordinators (CEPCs) to request available promotional items, which may vary. To identify their local CEPC, community members can send an email to Veterans Health Administration's Suicide Prevention Community Based Interventions at VHASPPCBISP@va.gov.

Downloadable Items

If you are looking for items to download (not printed/shipped to you), please visit our media page.

What type of outreach is this?

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Electronic Outreach

Care Package/Real World Outreach

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Order Date:

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M-D-Y

Days since 1/1/2020

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CONTACT INFO

Your Name:

(preferred prefix)

Contact Info:

		optional ext.

Will these items support an organization?

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Yes

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ABOUT THE ORGANIZATION

Organization Name:
Organization Type:
Your Role:

Which TWV community will these products support?

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most recent order date for this community (max days since 1/1/2020)

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last order date:

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Unable to complete order

Based upon availability, limitations are being set on the number of products that are able to be ordered. Communities are able to order once every 90 days. Our records reflect that you last placed an order on ______ (______ days ago). If you have special needs or requests please contact Dr. Joanna Sells at Joanna.Sells@va.gov.
You may now close this form.

Your Role in ______:

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Coordinator

Facilitator

Steering Committee Member

Team Member

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Your Organization

A Residential Address

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If you are not located in the U.S. or a U.S. territory and are interested in receiving products, please contact Melissa.McHarg@va.gov directly. Note: for international orders, costs for materials, handling and UPS shipping ONLY are covered by RMIRECC (any subsequent charges, including customs duty, freight, etc. are the responsibility of requestor).

Address:

Please note, our fulfillment service uses UPS therefore we are not able to ship to PO boxes (street addresses only please).

Please provide the ______ address that these items will be shipping to. Please provide the full address exactly as it should appear on a shipping label (including any info that will ensure package(s) will be delivered safely, such as floor, building or room number).

______ Mailing Address:





,
		(state)

Have you ordered from us before?

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How did you hear about Rocky Mountain MIRECC and our products/resources?

Social Media

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VA Referral or Outreach

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ORDER PRODUCTS

To order products enter or select the quantity desired next to the products below.

Risk ID Badges

Risk ID - Site Specific Information Screener Badge:

This badge can be used to display site-specific Risk ID and SPED information for your facility, such as phone numbers for warm handoff contacts or details about additional facility procedures. This information can be written on a sticker, such as a mailing label, and affixed to the badge.

(front)

(back)

Quantity:

*limit 300

Risk ID - Columbia Suicide Severity Rating Scale (C-SSRS) Screener Badge:

This badge lists the C-SSRS screener questions, skip logic, and positive and negative screening criteria.

(front)

(back)

Quantity:

*limit 300

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Together with Veterans

Pillboxes
Detail: Blue and Red, 7 Days		Quantity: *order in multiples of 20, limit 100
Tote Bags
Detail: Navy, 12"W x 13"H X 8"D		Quantity: *order in multiples of 20, limit 100
Magnetic Clips
Detail: Blue, 1-3/7"W x 3-3/8"H		Quantity: *limit 100
Wallet Card
		Quantity: *limit 400
Pens
Pen on one side and stylus on retractable clicker side, with black ink. Please note: pens may have slight variations as the previous pen style is phased out of inventory.		Quantity: *order in multiples of 20, limit 100
Window Decals
Detail: White, 4"H x 4"L		Quantity: *limit 300
Flashlight
Detail: On/off button activated flashlight with carrying strap, batteries included		Quantity: *limit 100
Magnets
Detail: White, 3.5" x 2"		Quantity: *limit 300
Hand Sanitizer
Detail: 1.9 oz		Quantity: *limit 40
Reducing Firearm Risks Brochure
Detail: 8.5 x 5.5		Quantity: *limit 100
Gun Lock
Detail: Grey		Quantity: *order in multiples of 100, limit 400

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Uniting for Suicide Postvention (USPV) Products

For additional postvention information and resources, visit the Uniting for Suicide Postvention (USPV) website.

Uniting for Suicide Postvention (USPV) Brochure
This full-color brochure introduces Uniting for Suicide Postvention (USPV), a website that provides resources for everyone touched by suicide loss. The aims of this brochure are to: Promote awareness about suicide loss and the role that postvention plays in facilitating healing over time Encourage open dialogue about suicide loss to help foster a community of shared healing Direct individuals to multimedia USPV resources that can help them navigate the journey that follows suicide loss Order this 8.5x8.5 brochure to share with patients, providers, co-workers, and friends at your facility or next event.		Quantity:
Uniting for Suicide Postvention (USPV) Magnent
This 4.4 x 2 rectangular magnet features the USPV logo and web-address. Order this magnet to share with patients, providers, co-workers, or friends at your facility or next event.		TEMPORARILY UNAVAILABLE
Uniting for Suicide Postvention (USPV) Picture Frame Magnet
This picture frame magnet is great for personal use or for sharing with colleagues and clients. This magnet has two pieces: Outer frame (4.25" x 6.25") - features the USPV logo and web-address and can hold a standard size (4 x 6") photo Inner pop-out magnet (3" x 4") - features the USPV "Postvention is Prevention" lotus/infographic		Quantity:
Uniting for Suicide Postvention (USPV) Notepad
This notepad is great for personal use or to share with patients, providers, co-workers, and friends or to have available at your next workplace event. The notepad is 4.25x5.5, with 50 college-ruled pages, featuring the USPV logo and web-address.		TEMPORARILY UNAVAILABLE

Uniting for Suicide Postvention (USPV) Repositional Sticker

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Talking to Kids About Suicide

For additional information and resources about talking to kids about suicide, visit the Talking to Kids about a Suicide Attempt in your Family website.

The below guides, in English and Spanish, for each specific age group can also be downloaded for printing on our Educational Products page.

How to Talk to a Child about a Suicide Attempt in Your Family Booklet & DVD- English
This is a 24 page full color booklet intended to provide parents/adults with support, and also share other resources that may be helpful for the parent as their family recovers. The guide is not intended to replace professional mental health advice. In fact, it may be best to use this along with professional support if you or your child is struggling with how to talk about this difficult subject.		Quantity: *limit 25
Cómo hablar con su hijo sobre un intento de suicidio en su familia: Guía para familias con niños en edad preescolar, niños en edad escolar y adolescentes - Folleto & DVD
Este es un nuevo folleto a todo color de 24 páginas destinado a proporcionar a los padres / adultos con el apoyo, y también comparten otros recursos que pueden ser útiles para el padre que recupera su familia. La guía no pretende sustituir el consejo profesional de salud mental. De hecho, puede ser mejor usar esto junto con la ayuda profesional si usted o su hijo tiene dificultades con la forma de hablar sobre este tema difícil.		Cantidad: *Que no exceda de 25

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Suicide Risk Management (SRM) Consultation Program

For additional Suicide Risk Management information and resources, visit the Suicide Risk Management (SRM) consultation program website.

Suicide Risk Management (SRM) Consultation Program #NeverWorryAlone Card
Rocky Mountain MIRECC's Suicide Risk Management Consultation Program is launching a new campaign, #NeverWorryAlone, to raise awareness of the program's expansion to include providers in the community in addition to VA providers. Help promote #NeverWorryAlone and bring this service to providers in the community serving Veterans. Order these handsome 3x5 cards to handout at your next event.		Quantity: *order in multiples of 25, limit 100
Suicide Risk Management (SRM) Consultation Program Pen
These pens are great tools for the office to be shared with colleagues, work teams and/or distributed at professional work and community events. Help us spread the word about the SRM Consultation Program by ordering and offering these pens at your next event. Each pen features the SRM logo.		TEMPORARILY UNAVAILABLE
Suicide Risk Management (SRM) Consultation Program Magnet
This lovely magnet features the SRM logo and web-address. Order your conveniently business card sized 3.5" x 2" magnet for personal use or to share with providers, colleagues and or friends at your facility or next event.		Quantity: *order in multiples of 25, limit 100
Suicide Risk Management (SRM) Consultation Program Notepad
This notepad is excellent for personal or professional use to share with providers, co-workers, and colleagues to have available at your desk and/or next workplace event. The notepad is 4.25" x 5.5" with 50 college-ruled pages, featuring the SRM logo and web address		Quantity: *order in multiples of 25, limit 100
Suicide Risk Management (SRM) Consultation Program Tote Bag
This tote bag is a useful carrier for personal or professional use for work and/or workplace events. It could be ordered and shared with your team, colleagues and guests of a conference or event you hold. The tote bag size is 14" x 14", featuring the SRM logo and web address.		Temporarily unavailable

Quantity:

*order in multiples of 25, limit 100

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Veteran Educational Resources

Veteran Apps and Resources Card

This Veteran Apps and Resources Card features on one side Coping and Symptom Management Apps and on the other various ways to connect with the VA. They are a quick and handy resource for Veterans and easily fit in with caring cards.

Quantity:

Temporarily

Unavailable

Treatment Works for Vets - Veteran Card

This card directs Veterans to Treatment Works for Vets, an online resource that introduces Veterans to Evidence-based Psychotherapies (EBPs). At Treatment Works, Veteran learn about proven treatments for depression, sleep issues, substance use, chronic pain, relationship distress and suicide prevention. Veterans choose their own path and are provided with options to locate their preferred treatment either through VA or in the community.

Quantity:

*order in multiples of 25

Preventing Suicide Among Older Veterans Brochure

This brochure helps family members and friends of older Veterans recognize the signs of suicide risk and learn how to talk to and support Veterans experiencing suicidal ideation. In addition, the brochure offers tips on decreasing suicide risk by making the home safer.

Preview the brochure online or download a digital copy.

Quantity:

*order in multiples of 25, limit 200

Give an Hour Card

This card gives information on accessing free mental health services for Veterans, military personnel, families and those who care for Veterans. It also shares the five signs of emotional distress, which are designed to help loved ones recognize when extra support may be needed.

Quantity:

*order in multiples of 25, limit 100

You're Not Alone in Recovering from Military Sexual Trauma (No Está Solo para Recuperarse del Trauma Sexual Militar)

This brochure developed by the VHA Office of Mental Health and Suicide Prevention provides information on VA health care services for individuals who experienced sexual assault or sexual harassment during military service, also called military sexual trauma or MST. It includes general information about MST, how it can affect survivors, and how to access VA's free MST-related healthcare services.

English:

Español:

Quantity (English):

Preview the brochure online or download a digital copy

*order in multiples of 25, limit 200

Quantity (Español):

Preview the brochure online or download a digital copy

*order in multiples of 25, limit 200

Strength and Recovery: Men Overcoming Military Sexual Trauma (Fortaleza y Recuperación: Hombres Superando el trauma Sexual Militar)

This brochure developed by the VHA Office of Mental Health and Suicide Prevention provides information on VA health care services for men who experienced sexual assault or sexual harassment during military service, also called military sexual trauma or MST. It includes general information about MST, how it can affect male survivors specifically, and how to access VA's free MST-related healthcare services.

English:

Español:

Quantity (English):

Preview the brochure online or download a digital copy

*order in multiples of 25, limit 200

Quantity (Español):

Preview the brochure online or download a digital copy

*order in multiples of 25, limit 200

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P60026 - IDO825 - Cards for Connection: Coping skills playing cards:

Link to the image online: https://www.mirecc.va.gov/visn19/images/5_cards.jpg

Title & Description:
Cards for Connection: Coping skills playing cards

These functional playing cards put simple coping skills and critical phone numbers directly into your hands. Each card has a different message, including positive affirmations ("I am worth it"), grounding techniques ("Describe 3 things you can see right now"), and useful phone numbers (e.g., the Veterans Crisis Line, the Women Veterans Call Center). The deck is enclosed in a waterproof plastic case. The cards were supported by the National Center for PTSD and VHA Innovators Network.

DVDs

The Treatment Works for Vets Website and Provider portal are currently being rebuilt and moved to a new URL. Please check back for the new URL and to order the updated Treatment Works for Veterans cards.

DVD: Substance Use and Traumatic Brain Injury Risk Reduction and Prevention
This seven-minute program provides information regarding the impact of using drugs and alcohol after a traumatic brain injury (TBI). The video guides the viewer through a discussion about how the brain works before and after a brain injury, and then demonstrates how drugs and alcohol can affect persons with a history of TBI using brain animations and short vignettes. This tool was designed to facilitate providers in engaging clients in a dialogue about substance use post-injury and was made possible by funding from the Congressionally Directed Medical Research Program.		Quantity: *limit 5
DVD: TIP 50 - Addressing Suicidal Thougths and Behaviors in Substance Abuse Treatment Training
Provides guidelines to help substance abuse treatment counselors work with suicidal adult clients. Covers risk factors and warning signs for suicide, core counselor competencies, clinical vignettes, and information for administrators and clinical supervisors.		TIP 50 is no longer available on DVD. The material is now available virtually and may be accessed on the multimedia page, found here.

unavailable wording: "Please note: TIP DVDs ship from VISN 2 Center of Excellence in NY. Currently, staff does not have access to product stock, and will be unable to ship until further notice. If you would like to place an order for TIP DVDs, it will be fulfilled as soon as possible."

Tools for Clinicians and Providers

Self-Directed Violence Classification System Nomenclature
The Self-Directed Violence Classification System (SDVCS) Nomenclature laminated sheet contains both the decision tree and the clinical tool grid. On the front is the SDVCS decision-tree to help lead the clinician to the correct self-directed violence term. On the back are the definitions. On a separate laminated sheet is a handy grid of SDV terms. Being laminated you will never after worry about spilling coffee on this hugely popular tool!		Quantity: *limit 200
Therapeutic Risk Management (TRM) with Patients at Risk for Suicide
The Risk Stratification Table is a tool designed to: help providers make determinations regarding suicide risk levels with respect to severity and temporality and to aid in suicide risk management clinical decision making. Learn more about the Therapeutic Risk Management with Patients at Risk for Suicide		Quantity: *limit 200

Evidence-based Psychotherapy Shared Decision-Making card

The provider portal at the Treatment Works for Vets website features the Evidence-based Psychotherapy Shared Decision-Making Toolkit for Mental Health Providers. This toolkit outlines key components and steps for implementing a pre-treatment Shared Decision-Making (SDM) session and promotes Veteran engagement in evidence-based psychotherapies (EBPs). The provider portal also hosts decision aids and clinician EBP resources.

Quantity:

*limit 200

Suicide Prevention CPG Provider Summary
This 30-page booklet covers the VA/DOD Clinical Practice Guidelines (CPGs) for Assessment and Management of Patients at Risk for Suicide, including the systematic review of both clinical and epidemiological evidence which the CPGs are based on. It is intended for use by clinical providers.		Quantity: *limit 200
Suicide Prevention CPG Pocket Guide
This double-sided, tri-fold brochure uses flowcharts to summarize key elements of the VA/DOD Clinical Practice Guidelines (CPGs) for Assessment and Management of Patients at Risk for Suicide. In particular, identification of patients at acute risk for suicide, comprehensive suicide risk assessment by providers, and management of patients at acute risk for suicide. It is intended for use by clinical providers.		Quantity: *order in multiples of 25, limit 200

Items By Request (not shown on order form)

VCL Promotional Item: Arm Band
VCL Promotional Item: Bandana
VCL Promotional Item: Beverage Holder
VCL Promotional Item: Dog Tag
VCL Promotional Item: Lip Balm
VCL Promotional Item: Pen
VCL Promotional Item: Pet bowl
VCL Promotional Item: Pillbox
VCL Promotional Item: Small magnet
VCL Promotional Item: Stress balls
VCL Promotional Item: Toothbrush kit
VCL Promotional Item: VA bag
VCL Stickers
Veterans Crisis Line wallet card
VCL Promotional Item: Notebook & Pen
VCL Promotional Item: Microfiber Cloth
VCL Promotional Item: Calculator
VCL Promotional Item: Socks
VCL Promotional Item: First-Aid Kit
VCL Promotional Item: Rainbow Lanyard
VCL Promotional Item: Squeeze Powered Flashlight
VCL Promotional Item: Pop Socket
VCL Promotional Item: Cutlery
VCL Promotional Item: Power Bank
VCL Promotional Item: Firearm Locks
VCL Promotional Item: Tissue
VCL Promotional Item: Rainbow Pin
VCL Promotional Item: Bottle
VCL Promotional Item: Folders

PRODUCT USE

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CONFIRMATION

Please confirm the below information you provided is correct before submitting your order.
Name: ______ ______ Provided Email: ______ Provided Phone: ______ Phone Extension (if applicable): ______
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______ ______ ______ ______ ______ ______, ______, ______ Station Number (if applicable): ______	*correct your address above as needed. Fields that you left blank will appear as blank lines.

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The Risk ID Screener badges are intended for VA internal use only. Press the button to confirm that you are ordering this product for use within VA.

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