Healthcare Crisis Assessment

HEALTHCARE CRISIS ASSESSMENT

Patient Identification

Patient Name:    Assessment Date:

Date of Birth:    Gender:

Emergency Contact

Name:    Relationship:

Insurance / Authorization

Presenting Crisis

Chief complaint / presenting problem:

Onset / duration of current crisis:

Clinical Assessment / Mental Status

Risk Assessment

Suicidal ideation: Yes    No

If yes, frequency/intensity:

Suicidal intent: Yes    No

Access to means (weapons, medications, etc.): Yes    No

History of attempts: Yes    No

Homicidal ideation/intent: Yes    No

Current risk level (select one): Low    Moderate    High

Substance Use & Medical History

Legal / Social / Previous Psychiatric Care

Safety Determination & Interventions

Is patient an imminent danger to self or others? Yes    No

Follow-up appointment scheduled for:

Legal Notices, Consent & Confidentiality

Confidentiality: Information in this assessment is confidential and will be maintained in the patient's medical record. The clinician may disclose information without authorization when required by law, including: to prevent an imminent threat of serious harm to self or others, to report abuse or neglect of a minor or vulnerable adult, or pursuant to a valid court order.

Consent for treatment and information sharing: By signing below, the patient (or legal guardian) acknowledges that they have been informed of the purpose of this crisis assessment, consents to emergency evaluation and treatment, and authorizes the clinical team to share necessary information with other health professionals and agencies involved in immediate care and disposition. This authorization is limited to information necessary to arrange timely treatment and safety measures.

Patient acknowledges receipt of privacy practices: Yes

Authorization expiration date for release of crisis information (if applicable):

Clinician / Assessor

Clinician Name:    Credentials:

Agency / Facility:

Sign Now