Crisis Response Services Kenora Rainy River District
Crisis Intervention Plan
Name:
Phone:
Address:
Birth Date:
Doctor’s Name:
Phone:
Emergency Contact:
Internal Use Only:
Phone:
Relationship:
Consent/Release
Provided
( ) Yes
( ) No
Support Person
Contact:
Date Received:
Phone:
Agency/Relationship:
Entered in Database:
( ) Yes
( ) No
yy___ mm___ dd__
Do you live alone?
( ) Yes
If no, Who else lives with you:
I have called the crisis line before
(
) Yes
(
(
) No
) No
When I am experiencing a crisis:
I feel: (i.e. sad, angry, suicidal, panic,
fear):________________________________________________________________
______________________________________________________________________
______________________________________________________________________
I usually behave: (i.e. withdrawn, yell, hurt myself, don’t eat):
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
These people, places or things upset me and can lead to a crisis
situation:
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Action Plan:
These are the things that I can do to help myself:
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
These are the things others can do to help me in a crisis situation:
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
These are the things that we can do together when I’m in crisis:
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
People who have helped me in the past and may help me now are:
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Actions that have not worked in the past when I’ve been in crisis:
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Risk History
History of Self Harm ( ) yes ( ) no Please describe:
________________________________________________________________________
________________________________________________________________________
_______________________________________________________________________
I have a plan for times when I’m at risk of hurting myself: ( ) yes ( ) no
Explain plan and who is involved:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
History of Harm to Others ( ) yes ( ) no
Information that might be helpful to us when assisting you:
_____________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Times when you feel hospital or police support would benefit you are:
________________________________________________________________________
________________________________________________________________________
Physical Description of me:
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Description of any physical health concerns:
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Description of my regular daytime activities:
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Description of any mental health concerns (Please indicate diagnosis
and date of diagnosis if applicable):
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Current Medications: (please provide drug name, dosage and what
the medication is for):
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Crisis Response Services
Kenora Rainy River District
Crisis Intervention Plan
Consent Form #1
I,
hereby authorize the information
contained in the Crisis Intervention Plan to be released to Crisis Response Services
Kenora Rainy River District. This information will allow for effective crisis service and
improve service delivery.
This authorization will remain valid for 6 months, or until I rescind or amend it. Should I
rescind this authorization, I may have the information contained within the Crisis
Intervention Plan amended or removed from my file, except in those instances where
action has been taken to provide me with crisis response service.
Signature
Signature of Service Provider/Support Person
(Must be identified in the Crisis Intervention Plan)
Date
Date
Crisis Response Services
Kenora Rainy River District
Crisis Intervention Plan
Consent Form #2
I, _____________________________ authorize Crisis Response Services
Kenora Rainy River District to release specific information to
__________________________________________
(Service Provider/Support Person identified in Crisis Intervention Plan)
in the event that
1. A Mobile Worker/Crisis Counsellor is dispatched by a Communicator
to meet with me;
2. Police, Ambulance, Child and Family Services, or any other
involuntary service is dispatched or notified by a representative of
Crisis Response Services regarding me;
3. An individual is admitted to the Stabilization Unit (and following
discharge);
4. There is a significant change in my situation.
This authorization will remain valid for 6 months, or until I rescind or amend it. Should I
rescind this authorization, I may have the information contained within the Crisis
Intervention Plan amended or removed from my file, except in those instances where
action has been taken to provide me with crisis response service.
Signature
Signature of Service Provider/Support Person
(Must be identified in the Crisis Intervention Plan)
Date
Date