1. Crisis Management: Suicide Risk Assessment A Guide for Mental Health Professionals
By: Jesus Quiroga

2. Presentation Overview
Overview of Suicide Prevalence
Purpose of Crisis Management
Definition of a Crisis
Crisis Prevention
Identifying a Crisis /Symptoms of a Crisis
Crisis Intervention
Safety Contracts
Proper Utilization of Resources
Crisis Resolution
Crisis Follow-up
Crisis Assessment & Documentation
Interviewing Skills
Mental Status Examination
Level of Risk

3. Age-adjusted suicide rates among all persons by state -- United States, 2001
Rates per 100,000 population
0.0 to 9.0
9.1 to 10.6
10.7 to 13.2
13.3 to 21.7
Source: Centers for Disease Control and Prevention (CDC) mortality data

4. Suicide in Texas, by County, 1989-1998 (CDC)
El Paso

5. Suicide by Age, Texas, 2004

6. Texas Suicides, 2004 TX US Total White Male WM BM Rate (%) 10.57 11.1
11.59 (92.5%)
12.3 (90.2%)
Male
17.33 (78.4%)
17.7 (78.8%) WM
18.78
(72.3%)
19.6
(71.2%) BM
9.66
(5.1%)
9.0

7. Suicide rates among males 15-19 years: 1980-2004
Suff rate is approaching the firearm death rate; poisoning decling

8. Suicide rates among males 10-14 years: 1980-2004
Note here that the sui by suff rate now exceeds the rate by firearms

9. Death Rates for Suicide by Age and Sex, 2003

10. Male Rates for Suicide by Race & Age, 2003

11. Purpose of Crisis Management
The goal of Crisis Management is to recognize early warning signs and symptoms in a person and prevent the situation from deteriorating into a crisis or worsening into an emergency situation.
Safeguard yourself and provide a blanket of security for the consumer and others involved.
Utilize effective Crisis Prevention strategies that encourage a collaborative partnership with the consumer and available community resources.
Use de-escalation techniques and other reactive measures to ensure safety
To bring the consumer to pre-crisis level of functioning.

12. What is a Crisis ? Self-Limiting, State of Disequilibrium
A crisis is not the precipitating event but the individual’s inability to cope with a situation
A person's thoughts and feelings are beyond their control.
A sudden deterioration in emotional or mental state
Expression of suicidal thoughts or actions
Potential of a serious risk to themselves or others
Expression of irrational and bizarre thoughts and behaviors that indicate they have completely lost touch with reality, i.e. hallucinations and/or delusions that potentially lead to dangerous situations

13. Crisis Prevention Knowing yourself Knowing your consumer
Proper and timely assessments
Providing medically appropriate services as per UM Guidelines (what is authorized in PIP)
Consistency
Appropriate & gentle confrontation
Referrals to community outreach programs/resources
Crisis planning
Attention to needs
If you can anticipate it you can intervene and prevent the crisis from exacerbating

14. Impending Crisis Subtle Attitude and Behavioral Changes (non-specific)
Complaining about having to take medications
Saying medication is not working or is not needed
Skipping or forgetting to take doses of medication
Missing scheduled appointments with mental health professionals, non-adherence
Doing less than usual during the day / low energy levels
Making too many changes at once (i.e., moving, changing jobs frequently, etc.)
Subtle changes in eating and sleeping
Trouble concentrating / focusing
Increase in smoking/ drinking
Pacing uncontrollably
Change in affect
Prevention of Deterioration to More Severe Symptoms
Mental Health Professional should encourage the consumer’s family/friends to track these changes daily (in writing)
These changes in attitude and behavior should be discussed with the consumer’s treating physician
The Mental Health Professional should work with the consumer and his/her family or friends on developing a crisis plan.

15. Symptoms of a Mental Health Crisis
These more severe and persistent symptoms can include (but not limited to):
Talk or plans of suicide/homicide
Abuse of alcohol or drugs
Dramatic  mood swings
Staying awake/asleep for periods exceeding 24 hours
Complete withdrawal from activities / loved ones
Bizarre behavior
Uncontrollable anger / fits of rage
Paranoia/suspicious
Obvious change in affect
Internally stimulated
Changes in attitude apparent
Refuses treatment / medications
Impaired Judgment / Poor insight
When the symptoms of mental illnesses become so severe that the individual is unable to manage basic self-care such as eating, bathing or dressing self
Judge the severity of the consumer’s reactions, not the “seriousness” of the event

16. More Severe Symptoms
Significant impairment in judgment that results in dangerous behavior
Walking the streets alone late at night
Getting into cars with strangers
Aggression / Violence
Sexually acting out
Gets verbally agitated
Yelling or cursing at people / ridicules people
Overreacts to frustrations that are usually handled calmly
Expresses paranoia directed at family, friends, or others
Accuses a family member or other person of poisoning their food
Accuses a family member of controlling their mind
Accuses a family member of putting thoughts into their head
States that a neighbor is breaking in at night and stealing things
Accuses a friend of being a spy or working with the CIA
States that a person is planning to kill them

17. The Continuum A crisis can be seen as a process
Not an isolated event but a process that has a build-up, peak, de-escalation phase, and resolution
A crisis may take a few hours or encompass several days even weeks

18. Why Does a Mental Health Crisis Occur?
A mental health crisis can occur for a variety of reasons and can be connected with life events which have become overwhelming:
Bereavement / Death of a loved one
Non-adherence to medications or treatment (consumers)
Prolonged periods of stress and anxiety
Severe Depression
Ailing health or chronic illness
Divorce / Marital conflict
Familial problems / Discord with a friend
Trauma (past and/or present)
Alcohol/Drug abuse (dependency)
A mental health crisis can still arise despite full adherence to medications or treatment.

19. Comorbidity and Suicide Risk
In general, the more diagnoses present, the higher
the risk of suicide.
Psychological Autopsy of 229 Suicides
44% had 2 or more Axis I diagnoses
31% had Axis I and Axis II diagnoses
50% had Axis I and at least one Axis III diagnosis
Only 12 % had an Axis I diagnosis with no comorbidity

20. RISK FACTORS Demographic
male; widowed, divorced, single; increases with age; white
Psychosocial
lack of social support; unemployment; drop in socio-economic status; firearm access
Psychiatric
psychiatric diagnosis; comorbidity
Physical Illness
malignant neoplasms; HIV/AIDS; peptic ulcer disease; hemodialysis; systemic lupus erthematosis; pain syndromes; functional impairment; diseases of nervous system
Psychological Dimensions
hopelessness; psychic pain/anxiety; psychological turmoil; decreased self-esteem; fragile narcissism & perfectionism
Behavioral Dimensions
impulsivity; aggression; severe anxiety; panic attacks; agitation; intoxication; prior suicide attempt
Cognitive Dimensions
thought constriction; polarized thinking
Childhood Trauma
sexual/physical abuse; neglect; parental loss
Genetic & Familial
family history of suicide, mental illness, or abuse

21. Areas to Evaluate in Suicide Assessment
Psychiatric
Illnesses
Comorbidity, Affective Disorders, Alcohol / Substance Abuse, Schizophrenia, Cluster B Personality disorders.
History
Prior suicide attempts, aborted attempts or self harm; Medical diagnoses, Family history of suicide / attempts / mental illness
Individual strengths /
vulnerabilities
Coping skills; personality traits; past responses to stress; capacity for reality testing; tolerance of psychological pain
Psychosocial situation
Acute and chronic stressors; changes in status; quality of support; religious beliefs
Suicidality and Symptoms
Past and present suicidal ideation, plans, behaviors, intent; methods; hopelessness, anhedonia, anxiety symptoms; reasons for living; associated substance use; homicidal ideation
Adapted from APA guidelines, part A, p. 4

22. Psychiatric Examination
DETERMINATION OF RISK
Psychiatric Examination
Risk
Factors
Protective
Factors
Specific Suicide
Inquiry
Modifiable Risk
Factors
Risk Level:
Low, Med., High

23. Family History/Genetics
Relatives of suicidal subjects have a four-fold increased risk compared to relatives of non-suicidal subjects.
Twin studies indicate a higher concordance of suicidal behavior between identical rather than fraternal twins.
Adoption studies: a greater risk of suicide among biologic rather than adoptive relatives.
Suicide appears to be an independent, inheritable risk factor.

24. Psychosocial: Life Stressors
Recent severe, stressful life events associated with suicide in vulnerable individuals
Stressors include interpersonal loss or conflict, economic problems, legal problems, and moving
High risk stressor: humiliating events, e.g., financial ruin associated with scandal, being arrested or being fired can lead to impulsive suicide.
Identify stressor in context of personality strength, vulnerabilities, illness, and support system.

25. Family Psychopathology
Family history of abuse, violence, or other self-destructive behaviors place individuals at increased risk for suicidal behaviors
History of childhood physical abuse and sexual abuse, as well as parental neglect and separations, may be correlated with a variety of self-destructive behaviors in adulthood

26. Components of Suicidal Ideation
Intent:
Subjective expectation and desire for a self-destructive act to end in death.
Lethality:
Objective danger to life associated with a suicide method or action. Lethality is distinct from and may not always coincide with an individual’s expectation of what is medically dangerous.
Degree of ambivalence - wish to live, wish to die
Intensity, frequency
Rehearsal/availability of method
Presence/absence of suicide note
Deterrents (e.g. family, religion, positive therapeutic relationship, positive support system - including work)
Remember to read the suicide note and document that you read it.
Beck et al. (1979)

27. Components of a Suicidal Plan
Risk / Rescue Issues:
Method
Time
Place
Available Means and Access
Arranging Sequence of Events
Jacobs (1998)

28. Protective Factors
Children in the home, except among those with postpartum psychosis
Pregnancy
Deterrent religious beliefs
Life satisfaction
Reality testing ability
Positive coping skills
Positive social support
Positive therapeutic relationship

29. Suicide SUICIDE: A MULTI-FACTORIAL EVENT
Psychiatric Illness Co-morbidity
Personality Disorder/Traits
Neurobiology
Impulsiveness
Substance Use/Abuse
Hopelessness
Severe Medical
Illness
Suicide
Family History
Access To Weapons
Psychodynamics/
Psychological Vulnerability
Life Stressors
Suicidal
Behavior

30. Validate the Crisis VALIDATE feelings, not INSTRUCT on how to feel
Remember that you are ignorant of another person’s experience
Show understanding of the current situation / event
Acknowledge their reactions
Assist in reviewing their options
Provide emotional support
Provide empathy / compassion

31. Approach: Establish Rapport
Sometimes in our business: You begin to see clients as “different” than yourself:
Consider the person’s experience age, educational level, developmental stage, and culture
Use language appropriate / contextual
Watch body language / facial gestures
Encourage discussion
Be objective
Keep composure
Set Limits / gently confront
Be genuine—If you’re being fake, a consumer will know
Be patient—watch the momentum of your assessment and the pace of your questions
Otherwise resolution will not be long term / efficacious

32. Crisis Intervention: Cautionary Probing
Gauge the severity of the behavior and amount of insight into reality
If the consumer’s sense of reality allows, ask ample but not an overwhelming amount of open-ended questions
Get as much collateral information as possible (weigh possible ulterior motives from family members or possible exploitation)
Be careful about the established relationship (do not rely on rapport)
Balance information from the past and the current situation
Assess the direction of your questions (do not ask leading questions)
Do not aggravate open wounds (deviate as you see visual cues of agitation)

33. Communication Skills Normalizations Assists in expression of emotions
Decreases feelings of isolation
Pre-normalization
A lot of the people who struggle with _________ report feeling a sense of shame. Has that been going on for you?
Examples
It’s normal to feel angry sometimes
It’s not uncommon to feel angry

34. Interviewing Skills Open Questions Generates dialogue and discussion
Assists in gathering information important to the person you are speaking with
Examples
Tell me more about your situation
Who in you life can you turn to for support?
How has this affected your life?

35. Interviewing Skills Closed Questions Helps gather specific information
Used to clarify
Examples
Do you want to talk about it?
Have you told anyone about this?

36. Interviewing Skills Paraphrases Summarizes and clarifies
Contains feelings and content
Examples
So what I’m hearing you say is that you didn’t get the response you wanted from social services.
Am I correct in saying that you’re sad because ex-partner is moving?

37. Interviewing Skills Questions to Avoid “Why” Questions
Leading Questions
Multiple Questions

38. There are many listening models this is just a basic outline of the stages.
What models do you use?
Ask how they would establish rapport?
What does a helper focus on concern?
How do you support a caller or client?
How do manage the end of the call?
How can you prevent circular calls?

39. Crisis Intervention: Safety
Ensure the safety of yourself, the consumer, and others
Clear the area of other non-essential people and ensure privacy if you can
Locate / remove potential hazards in the room
Note exits, phones, and where others are located
Approach the person in a non-threatening and calm manner – they are likely to be very confused and frightened
Attempt to reassure the individual

40. Crisis Intervention: Prevent Escalation
De-escalate:
Prevent escalation –emotion turns into adrenaline
YOU must be calm under very trying circumstances
Allow time to pass (cool off)
Sometimes de-escalation is not an option
Authorities (911) must be involved for safety reasons
If you are uncertain that this is the correct course of action, then call a supervisor
Most Importantly: LISTEN

41. Intervention: Control Emotions
Stay calm
You must be aware of your own thoughts, reactions, feelings, and behaviors
Avoid directives with upset consumers such as:
“calm down”, “you shouldn’t feel so angry”, “relax”
Modeling is more effective:
Demonstrate a calm even tone, even breathing, and sympathetic voice, keeping calm at all times
Avoid non-verbal behaviors that suggest frustration, condescension, or agitation on your part

42. Crisis Intervention: Reality Orientation
Your role is to assist consumers in gaining a more realistic perspective on emotional state and the precipitating event.
While listening to a consumer, clarify feelings and relate them to specific causative factors.
If the consumer is still feeling incapable of coping, point out how reactions / negative thinking are exacerbating the problem.

43. Crisis Intervention: Course of Action
Clarify Problems
Develop Alternatives
Agree on a Course of Action
Utilize Family members / friends if appropriate
Encourage linkages with other
Individuals / Family
Agencies / Professionals
Evaluate severity of risk

44. Crisis Intervention: Evaluate Severity of Risk
Ask questions that relate to risk factors for lethality:
Asking questions that can determine if hospitalization is a medically necessary alternative or if a lesser restrictive option is the most suitable and clinically appropriate course of action
FIDO:
Frequency
Intensity
Duration
Objective Plan
Go with your clinical gut

45. Crisis Intervention: Safety Contract
Safety plans and no-harm contracts
First order of business:
How will your consumer stay safe?
Who will help the consumer in a crisis?
Who will they call once a crisis begins?
What will they do if crisis erupts?
Where will they go in a crisis?
These plans are not for us they are for the consumer
The consumer needs to show ownership by collaborating, signing, and keeping a copy of the contract
Consistent review of the plan is necessary to ensure progress

46. Crisis Intervention: Safety Contract
Part of the plan should include follow-up phone calls and sessions with the primary professional
If the plan was successful, encourage the consumer during other sessions to keep up with strategies
Ensure accountability

47. Suicide or Safety Contract
Problems:
Commonly used, but no studies demonstrating ability to reduce suicide.
Not a legal document, whether signed or not.
Used pro-forma, without evaluation by psychiatrist.
Possibilities:
Useful when there is positive therapeutic relationship (do not use when covering for colleague).
If employed, outline terms in patient’s record.
Useful when they emphasize availability of clinician.
Rejection of contracts have significance.
Bottom line – still considered within standard of care

48. Crisis Intervention: Final Analysis
You’ve assessed risk and you have discovered:
The consumer is in danger and not able to stay in the community. Follow Crisis/ Intake procedures, follow-up with supervisor. Or
The consumer has de-escalated within a clinically reasonable amount of time and able to return home.

49. Crisis Unresolved Hospitalization is necessary:
Imminent danger to self / others
Has a plan to execute threats to self / other
Several courses of action
Have consumer assessed further by an M.D. or Licensed Counselor
Call 911 if an individual is in immediate danger or If medical emergency arises prior / during crisis
Refer Police to EPMHMR Intake for determination / appropriateness for admission to inpatient treatment
Call EPMHMR Crisis Line (915) (24hours,365 day) for Mobile Outreach to assess consumer ( as appropriate)
Staff must provide on-going crisis intervention
Complete an Emergency Detention form by any Adult
Coordination between, Police, EMS (if involved) EPMHMR Crisis/Intake, El Paso Psychiatric Center (or identified hospital)

50. Crisis Resolution
Consumer has demonstrated without question that they are not a threat to self or another person
De-escalation has lasted for an appropriate length of time, to be determined by the severity of the event crisis and the consumer’s ability to gain control of emotions and actions
Medication has been administered and the above has been demonstrated
An M.D. or licensed professional has deemed consumer safe to go home and does not recommend inpatient treatment
Consumer is sent home (if available with family) or to a temporary respite where safety is assured

51. Crisis Resolution: Follow-Up
Establish open communication to Prevent Future Incidents:
All treatment team providers should be notified of incident or crisis situation
Supervisor
Case Manager
Rehab Worker
Doctor (if appropriate)
Family member (if appropriate)
Document all actions and interventions

52. Crisis Resolution: Preventing Recidivism
Follow-Up session within 24 working hours
Trag Assessment and Provider Implementation Plan (PIP) or treatment plan
Should be revised and amended as appropriate as consumer’s needs have possibly changed
Frequency of sessions and treatment objectives may need to be reviewed
Family members and all treatment team members should be involved in any revisions
Modifications to medication can be adjusted as clinically deemed by a medical professional

53. What to Document in a Crisis Assessment
The risk level
The basis for the risk level
The treatment plan for reducing the risk
Example:
This 62 y.o., recently separated man is experiencing his first episode of major depressive disorder. In spite of his denial of current suicidal ideation, he is at moderate to high risk for suicide, because of his serious suicide attempt and his continued anxiety and hopelessness. The plan is to hospitalize with suicide precautions and medications

54. Mental Status Exam, What is it?
The mental status examination (MSE) is based on your observation of the client.
It is not related to the facts of the client’s situation but to the way the person acts, talks, and looks while in your presence.
This can be an abbreviated process or one that takes place over several interviews..
The MSE always has the same content, and you write your observations in roughly the same order each time.
Use descriptions and whenever possible use direct quotes.

55. What to Observe: General appearance Behavior
Thought process and content
Affect
Impulse control
Insight
Cognitive functioning
Intelligence
Reality testing
Suicidal or homicidal ideation
judgment

56. Orientation and Level of Consciousness
Lethargy: trouble remaining alert and appears to want to drift of to sleep
Oriented x3: knows who they are, where they are, and when it is
Ask for the current date: reasonably accurate dates are acceptable
Ask where the person is
Ask who the person is and or DOB

57. Insight and Judgment
Insight is having a realistic understanding of a situation. For example, a person with poor insight into their drinking problem may genuinely believe that there is no problem and their behavior is appropriate.
Judgment is the ability to critically evaluate the situation and make good decisions about a course of action.

58. Appearance
Always indicate when you this is present. It involves such things as body odor, looking disheveled, or an unkempt appearance. Would include dirty, stained, or rumpled clothing.

59. Attitude and Interpersonal Style
Always note hostility, aggressiveness, rudeness, uncooperativeness, sarcasm
Always note if a person is uncooperative.
Always note boundary violations. This occurs if the person is too friendly, touches you, or attempts to draw you out personally

60. Behavior and Psychomotor Activity
Always indicate any mannerisms you see and any posturing.
Always indicate tension, particularly if the person seems tense and the interview does nothing to relax the person. This can include tensed fist, or an otherwise stiff posture.
Always note severe akathisia (restlessness). It can be part of an illness, a sign of withdrawal, or a medication side effect. Try to establish when it started, how long it has gone on, and if it has gotten worse.

61. Behaviors and Psychomotor Activities
Always note:
Pacing
Fidgeting
Nail biting
trembling or tremulousness
Rocking
Bouncing
Grimacing (particular strange facial movements)

62. Tardive Dyskinesia:
Occurs when psychiatric patients have been on antipsychotic medications over a long period of time.
The term literally means “late appearing abnormal movements”
Involves the muscles of the face, mouth, and tongue. Sometimes the trunk and limbs are also affected
Movements can be quick or slow.
All the movements are brief, involuntary, and purposeless.
A person may twist the tongue and lips, make odd faces, bounce or tap the feet, or actually writhe and squirm in the seat.

63. Catatonic Behavior
A sign of severe depression or schizophrenia, catatonic type.
Generally appears as a rigidity of posture where attempts to reposition the person are rigidly resisted.
The person may pose in bizarre and inappropriate ways.
One form, waxy flexibility, is when the limbs of the person will remain in the position in which they are placed.

64. Speech and Language
Pressured: often rapid but constantly talking; cannot be interrupted. Thoughts appear to be racing.
Monotonous: no variation in tone
Emotional: very expressive
Accented: note a native accent and also if the patient seems to accent certain words or syllables
Impoverished: may say very little either because of depression or because they are being interviewed in a language other than the native tongue. May indicate some lack of facility with language.
Neologisms: Made up words with idiosyncratic meanings. This can happen with because of brain injury due to accident or stroke.

65. Aphasia
Loss of ability to understand and produce language; damage usually to left hemisphere of the brain (left-handed people often have this in the right hemisphere).
Global: can neither speak nor understand
Broca’s aphasia: can understand written and spoken language, but has trouble expressing own thoughts verbally
Wernicke’s aphasia: inability to understand language and uses fluent, bizarre, nonsensical speech. The person may also act strange and appear euphoric, paranoid, or agitated. Note: In schizophrenia the person is usually able to write and speak, repeat words, and name objects.
Perservation: repeating a verbal or motor response to a prior stimulus even when confronted with something new. May give the same answer to different questions, stay on the same topic, or repeatedly return to the same subject

66. Mood Euthymic: normal mood
Expansive: feels very good and is getting better
Euphoric: giddy and happy
Anxious: worried and distressed

67. Sleep Disturbance Initial insomnia: trouble falling asleep
Middle insomnia: waking up in the middle of the night
Terminal insomnia: early morning wakening. Depressed individuals will often wake several hours earlier than usual and feel most depressed in the mornings.
Hypersomnia: sleeping too much.

68. Memory
Short term memory: immediate recall limited to about seven items and generally lasts for about one minute.
Long-term memory
Amnesia: inability to remember
Anterograde amnesia: cannot learn NEW material
Retrograde amnesia: cannot recall recent past events

69. Memory Testing As if they have had problems with memory.
Test immediate recall using a random list of digits asking the person to repeat them. Start with two and keep adding digits until two consecutive failures.
Test recent memory by asking them what happened in the last few hours or days before coming to see you.
Test remote memory by asking the client to recall events in their lives and commonly known public events that happened in years past.

70. Thought Content
Distortions: a person distorts a part of reality. A woman with anorexia believes she is fat when she is thin.
Delusions: an inappropriate idea from which a person cannot be dissuaded using the normal means of argument or evidence. Delusions indicate psychosis.
Paranoid delusions: being singled out for harassment or are being controlled by forces outside of themselves.

71. Disordered Perceptions
Illusions: the person either misperceives or misinterprets a sensory stimulus. A tree branch brushing the side of the house in the winds sounds like people entering the house or a fan sounds like people talking in another room.
Hallucinations: in the absence of external stimuli, the person perceives something. The most common hallucination is hearing voices but there can be visual or hallucinations that are smells. If the person hears voices try to determine who is talking, what they are saying, how the person feels about it, and is there a command to do something.
Depersonalizations: the person feels estranged or detached from self.
Derealization: the person feels detached from what is going on around them. A person who dissociates cannot always be sure that what is happening is real.

72. Delusions Common to Schizophrenia
Thought withdrawal: one’s thoughts are being taken out of one’s mind by an outside force
Thought insertion: thoughts are being placed into the mind
Thought broadcast: thoughts are being taken and broadcast so that others know
Suspiciousness: always describe this and report the object of the suspicion
Grandiose delusions: false belief that one is extremely important or imbued with special powers.
Somatic delusions: false beliefs about health
Magical thinking: thinks they have magical powers with words, thoughts, or actions. This thinking is found in children who have not developed reality testing.

73. Reliability
Briefly state you impression of the clients’ reliability and accuracy in giving you the details of their situation.
If a person is psychotic, the material presented is likely to be extremely unreliable.

74. Debriefing Utilization of Peers for Debriefing
Prevention of Secondary Trauma

75. Intake & Crisis Emergency Services 24 Hours, 7 Days a week, 365 a Year
1600 Montana
El Paso, TX 79902
(915) Crisis Hotline
Array of Services:
Crisis Hotline
Mobile Crisis Outreach (E.R. Based)
Mobile Crisis Outreach (Community Based)
Walk-In Crisis Services (Site Based)
Walk-In Outpatient Services (Site Based)
Remote Walk-In Services (RV) (Tele-Psychiatry)
Crisis Follow-Up

76. Open Forum for Questions
Thank You
Open Forum for Questions