CRISIS INTERVENTION NOTE

Client: [Name, age, pronouns, record number if known]
Date: [Date]
Times: [First contact, end of contact, and total minutes]
Contact type: [Walk-in, phone, text or chat, mobile crisis visit, or unplanned session]
Client's location: [Address confirmed at the start, and a callback number for phone, text, or video]
Reached us through: [Self, family, friend, school, police, another clinician, or a crisis line]
Others involved: [Name, relationship, and what each person did during the contact]
Known to the service: [Current clinician, diagnosis, medications, and last contact, or new]
Clinician: [Name, credentials, role]

PRECIPITATING EVENT
What happened: [The event behind the crisis, and when]
Why now: [What made the client or others reach out today]
Client's account: [A short quote]
Collateral: [What family, friends, police, or records added, with consent or the reason for going ahead without it]

PRESENTATION
Appearance and behavior: [Dress, grooming, eye contact, agitation, cooperation; for a call, voice and pauses]
Mood and affect: [Mood in the client's words; affect observed or heard]
Thought and perception: [Process, hopelessness, guilt, voices, beliefs about death]
Orientation and judgment: [Alert, oriented, able to take part in decisions]
Intoxication: [Substance, amount, last use, and whether a full assessment is possible now]
Injuries and medical needs: [Wounds, overdose, or illness, and how each was handled]

RISK ASSESSMENT
Suicide: [Thoughts, method, intent, plan, preparation, visits to the site, past attempts; screener and result, such as the C-SSRS]
Self-harm: [Method, how often, most recent episode, and intent in the client's words]
Harm to others: [Thoughts, threats, a named person, access to weapons]
Self-neglect: [Eating, sleep, medications, shelter, ability to care for self]
Lethal means: [Firearms asked about directly; medications at home; the method in any plan]
Dependents and safety at home: [Children or others in the client's care; violence or abuse]

PROTECTIVE FACTORS
Reasons for living: [In the client's words]
People available now: [Who can be with the client tonight, and whether they were reached]
Engagement: [How the client took part, and their willingness to accept help]
How much they hold: [Whether these factors are lowering the risk right now]

INTERVENTIONS
De-escalation: [What you did to lower distress and slow things down, and the effect]
Safety planning: [Safety plan written, reviewed, or left for the next service, and where the client's copy is]
Lethal means counseling: [What was agreed for each means, who will do it, and how it will be confirmed]
Supports contacted: [Who was called, with consent, and what they agreed to do]
Crisis contacts given: [988 by call or text, local crisis team, 911, nearest emergency department]
Consultation: [Supervisor, psychiatrist, or on-call clinician, and their advice]

DISPOSITION
Decision: [Home with a safety plan and follow-up, crisis stabilization, voluntary emergency assessment, or involuntary emergency assessment under the law where you practice]
Reasoning: [The facts that made this the safest option, and what would change it]
Client's view: [Agreed, agreed with reservations, or declined, in the client's words]
Transport and handoff: [How and with whom the client left, and the report given to the receiving team]
If the plan fails: [What you would do if the client declined, left, or the contact dropped]

CONSENT AND WHO WAS TOLD
Shared with consent: [Who, what, and why]
Shared without consent: [Who, what, and the legal or policy basis, or none]
Young person or dependent: [Parent or guardian told, what was shared, and the young person's view]
Kept private: [Anything the client asked to keep private, and whether it was kept]

FOLLOW-UP
Next contact: [Date and time, within a set number of hours, who makes it, and how]
If no contact: [Who reaches out next, when, and the step after that]
Tasks and plan changes: [Records, referrals, or messages to send, each with a due time; treatment plan, safety plan, or level of care updates]

Signed: [Name, credentials, date and time]