Pre-Screening Questions


Animals in the home, are they friendly? Yes       No


Besides kitchen knives, is there anything in the home that can be used as a weapon? Yes       No

Involvement with outside agencies/state offices?  Yes       No


Is the client aware services are being provided?    Yes       No

Suicidality (check one for each below)

PLAN:            Yes       No

INTENT:        Yes       No

MEANS:        Yes       No


Danger to others (check one for each below)

PLAN:            Yes       No

INTENT:        Yes       No

MEANS:        Yes       No

Self-Injury:  Has client done anything to hurt self?  - Yes       No


Substance Use:  Is client drinking or currently using drugs? -  Yes       No

Immediate Follow up Needed:

  Emergency Services Contacted (911)

  Immediate dispatch by crisis staff

  Crisis clinician to follow up within 24 hours

  Primary clinician to follow up

  Medication Management follow up needed

Healthy Minds. Healthy Communities.