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