WOOD COUNTY CRISIS INTERVENTION STAT FORM

In Programs by NAMI Wood County

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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.

Starting time of call:
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Ending time of call:
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SUBJECT INFORMATION
SUBJECT CRISIS
Type of crisis:Based on current interaction with individual in 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:
MENTAL HEALTH AGENCY INVOLVEMENT
Time Agency was Contacted:
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Time Agency Arrived:
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LAW ENFORCEMENT
COMPLETED BY
FOLLOW UP
Requesting follow up with the individual by a mental health professional:If yes, please fill out the contact information for the individual.
Officer SatisfactionWas the officer satisfied with the outcome?
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