MENTAL HEALTH CRISIS REPORTING FORM
ADULTS: KITTSON, NORMAN, MAHNOMEN, MARSHALL, PENNINGTON, POLK, ROSEAU, & RED LAKE COUNTIES
CHILDREN: KITTSON, NORMAN, MAHNOMEN, MARSHALL, POLK, & RED LAKE COUNTIES
Agency Completing Form:
CHECK ALL THAT
APPLY:
FACE-TO-FACE
CONTACT LOCATION
PRIMARY REFERRAL
SOURCE:
CONTACT DATA:
Staff Completing Form:
Contact Date(s):
PHONE CONTACT WITH CLIENT
CONTACT TIME (15 min.):
FACE-TO-FACE CONTACT WITH CLIENT:
CONTACT TIME (15 min.):
Assessment:
+ Intervention
+ Stabilization
=Contact Time
CONSULTATION WITH PROFESSIONALS - Phone or
Face-to-Face
CONTACT TIME (15 min.):
Who:
TRANSPORTATION ( time with client
&
without client
)
CONTACT TIME (15 min.):
From:
To:
Client’s Residence Crisis Team Office Other Mental Health Provider Public Location
Private Residence
Homeless Shelter
Emergency Room
Other:
Self, family, friend
Health Plan
Probation Officer Primary care physician
School
Law Enforcement
Hospital
Community Mental Health Provider/ Case Manager Residential treatment or foster care provider
Unknown
Other (describe):
Name:
Social Security Number:
Place/Phone Number to Reach Client at Time of Referral:
Client Address:
Current Client Status:
New Client
Continuing Client
Insurance:
Medical Assistance (MA) Policy #
MH Crisis Plan Available:
Yes-available and utilized
Select One:
911
CLIENT DATA:
Date of Birth:
County of Responsibility:
Gender: Male
Female
Other
Client Phone Number/s (if different):
Provisional Diagnosis:
Commercial (name):
Policy#
No- Exists NOT utilized Yes-available NOT utilized
DSM Code
None
No-does not exist
Complete the following for MINORS only (17 & under): If over 17 proceed to next section
Face-to-Face Immediate
Face-to-Face within 24 Hours
Phone Consult Only
White
American Indian or Alaskan Native Black/African American
Native Hawaiian/Pacific Islander Asian
Unknown
Other race (list):
ETHNICITY:
Latino or Hispanic
Hmong/Laotian
Somali
None Other (list):
LANGUAGE AT HOME: (primary only):
English
Hmong
Spanish
Somali
Other (list):
HOSPITALIZATION in past year:
Yes
No
Unknown
RESIDENTIAL TREATMENT in past year:
Yes No
Referral Only
RACE:
Unknown
Complete the following for ALL ADULTS only (18 & over):
PMI#:
Legal Status at Start date:
or SMI#:
no SMI#
Voluntary-Self Voluntary-Others (by Guardian, Parent, Etc.) Civil Commitment MI
Civil Commitment MICD
Civil Commitment MI/DD Civil Commitment MI&D Civil Commitment – Sexual Civil Commitment – Other
Court Hold Criminal Commitment Emergency Hold Provisional Discharge Unknown
Race:
American Indian and Alaskan Native Asian
Black or African American
Native Hawaiian/Pacific Islander
White
Some Other Race Alone
Unknown
Ethnicity:
Not of Hispanic Origin
Puerto Rican
Mexican
Cuban
Other Specific Hispanic
Hispanic Origin regardless of race Unknown
Reside on Reservation:
No – does not reside on Reservation Bois Forte Fond-du-Lac Grand-Portage Leech Lake
Lower Sioux
Mille-Lacs Band Prairie Island Red Lake
Shakopee
Upper Sioux
White Earth Other
Unknown
Tribal Enrollment:
Bois Forte Fond-du-Lac Grand-Portage Leech Lake
Lower Sioux Mille-Lacs Band Prairie Island
Red Lake
Shakopee
Upper Sioux
White Earth
Other
Not Enrolled Unknown
Residential Status:
Unknown
Private residence – independent
Private residence – dependent
Foster Care/Foster Home
Homeless/Shelter
Crisis Residence Residential Care
Institutional Setting
Jail/Corrections facility
Other
Employment Status:
Employed full-time > 32 hours/week)
Employed part-time (< 32 hours/week) Looking for work/ Unemployed
Not in the Labor Force:
Homemaker
Student
Retired
Disabled
Hospital Patient or Resident of Other institutions
Other reported classification (volunteers)
Sheltered Employment
Unknown
Education Enrollment Status:
Enrolled
Not Enrolled Unknown
Highest Education:
Grade 1
Grade 2
Grade 3
Grade 4
Grade 5
Grade 6
Grade 7 Grade 8
Grade 9
Grade 10
Grade 11
Grade 12/GED
Voc/Tech School
College Freshman
College Sophomore
College Junior
College Senior
Graduate/Professional School Unknown
Number of Arrests in the past 30 days:
(00-30)
Unknown
Veteran Military Status:
No Yes, no combat Yes, served in combat zone Yes, combat unknown
Unknown
Is Veteran Receiving VA Mental Health Services?
Yes
No
Unknown
Children under 18 years of age: Children Age Range(s):
0-5 Children Reside with the Client:
Children have Special Needs:
Yes
No
Unknwn
6-11
12-17 Unknwn
Full-time Part-time Not at all Unknwn
Yes
No Unknwn
Diagnostic Assessment
Date:
/
/
Axis I:
(209-316)
Substance Abuse Screening:
Rev. January 2014
Axis II:
(301; 317-319;
999.9996-999.9997)
Screened – Negative
Axis III:
(001-289; 320-759; 780-999;
V01-V 86; 999.9996-999.9998)
Screened – Positive
Not Screened
Axis V- GAF
(0-100 )
997 Unknown
MENTAL HEALTH CRISIS REPORTING FORM
ADULTS: KITTSON, NORMAN, MAHNOMEN, MARSHALL, PENNINGTON, POLK, ROSEAU, & RED LAKE COUNTIES
CHILDREN: KITTSON, NORMAN, MAHNOMEN, MARSHALL, POLK, & RED LAKE COUNTIES
INCIDENT DATA: (form will expand to accommodate notes)
Suicidal (ideation)
Suicidal (attempt)
Self-Injurious Behaviors (non-suicidal)
Anxiety/Panic
Trauma (assault, loss, abuse)
Aggressive, threatening, or homicidal behaviors
Depression
Situational Crisis
Challenging, disruptive, out of control behavior
Mania
Psychotic or delusional (no threatening behaviors, non-assaultive)
Other (MUST describe, e.g., grief, parenting concern, substance abuse) :
Current Stressors/Nature of Problem/Current Symptoms/Risk Behaviors/Problems:
Is alcohol or drug use influencing the current mental health crisis?
Yes
No
Prescription Medication(s) Known:
OUTCOME: (form will expand to accommodate notes)
Brief Description of Outcome:
Client Whereabouts Known at Episode Closing?
Yes
No
Complete the following for MINORS only (17 & under)
Immediate Disposition:
Coordination
Hospitalization
(All that Apply)
Shelter Placement
With Case Manager
Emergency Foster Care
With CTSS Provider
Temporary residence with
Other (list):
relatives/friends
Remained in current home
Other (MUST specify):
Complete the following for ADULTS only (18 & older)
Referrals Made (new services you
Case Management
arranged, not services in place):
E.D./Psychiatric Hospital
Not Receiving, Appoint.Arranged
Residential Treatment
Already Receives, Sharing Info
Physician/Psychiatrist/CNS
Not Receiving, Referral Declined
Additional Mental Health
Already Receives, NOT Sharing Info
Services
Not Receiving, Not Referred
Chemical Health Services
Other (Must Specify):
________________________________________ ______________
Staff Signature
Date
__________________________________________ ________________
Supervisor Signature
Date
________________________________________ ______________
Client Signature ( Refusal/List Reason above) Date
__________________________________________ ________________
County Director Signature/Approval
Date
COMPLETE THE FOLLOWING SECTION ONLY FOR CHILDREN (17 & UNDER) RECEIVING STABILIZATION SERVICES:
Name (if given):
Date of Birth:
County of Responsibility:
Contact Date:
*IF STABILIZATION SERVICES WERE PROVIDED FOR AN INDIVIDUAL AGED 0-17, PLEASE COMPLETE THE FOLLOWING:
CASII Score:
Other Services (all that apply)
Individual Psychotherapy
Group Therapy
Family Psychotherapy
Individual Skills Training
Group Skills Training
Family Skills Training
Mental Health Behavioral Aide
Day Treatment
Current
Referrals
SDQ Scores: Parent
Self
Teacher/Case Manager
Other Services (cont)
Current
Residential Treatment
Case Management (Children’s Mental Health)
Medication management – Psychiatrist
Medication management – Primary care provider
Partial hospitalization
Inpatient hospital services
Support groups
None/unknown
Referrals
________________________________________ ______________
Staff Signature
Date
*PLEASE SEND FORM TO THE CRISIS COORDINATOR AT NWMHC 603 BRUCE ST. CROOKSTON, MN 56716 FOR PROCESSING
Rev. January 2014