WOOD COUNTY CRISIS INTERVENTION STAT FORM

TO BE COMPLETED ANY TIME A CRISIS SITUATION IS ENCOUNTERED.

Agencies participating in the Crisis Intervention process strive to keep this information accurate based on the views, opinions, and observations effected solely on this incident and is intended to provide general information and should not be used as a substitute for a professional evaluation. Furthermore, the above named department and the Wood County Sheriff’s Office take no responsibility for the accuracy or validity of any contents and make no representation about any information provided and disclaim all liability.

Incident Number:

Date:

Location:

Starting time of call:

Ending time of call:

SUBJECT INFORMATION

First Name:

Middle Initial:

Last Name:

Contact Information:Include guardian information if applicable.

County of ResidenceIf you selected "other" above, enter residence here

Phone Number:Required for Mental Health Professional follow-up.

Email:Required for Mental Health Professional follow-up.

Interaction CommentsHave you interacted with this individual often? Not always a CIT call? Enter more info here.

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SUBJECT CRISIS

Suicidal thoughts are pervasive thoughts about death, dying, or killing oneself - not to act on it.

Suicidal threats would be if they had thought out a plan to die by suicide.

Non-Suicidal Self Injury refers to any current self-harm used as a negative coping skill - i.e., cutting (with blades, paper clips, other sharp objects), excessive drinking, excessive drug use - without the intent to kill oneself.

Involvement of Drugs/Alcohol:

DrugsAlcoholNoneUnknown

If so, elaborate violent or aggressive behavior:

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Force Used by Officer:

Officer Notes and Additional Information:To include On-Going Services or Social Supports.

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MENTAL HEALTH AGENCY INVOLVEMENT

Time Agency was Contacted:

Time Agency Arrived:

OTHER AGENCY INVOLVEMENT

LAW ENFORCEMENT

Follow-Up or System Concerns:

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COMPLETED BY

Officer's Name:

Title:

Contact Information (for Officer):

Officer Email (for copy of submission):

FOLLOW UP

Requesting follow up with the individual by a mental health professional:If yes, please fill out the contact information for the individual.

YESNO

Officer SatisfactionWas the officer satisfied with the outcome?

YESNO

If not, please elaborate?

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