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

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Involvement with outside agencies/state offices?  Yes       No

 

Is the client aware services are being provided?    Yes       No

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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

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

 

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

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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