SCCS Mobile Crisis Evaluation Form w/ Columbia

Mobile Crisis Evaluation Form

South Central Crisis Service
Client Name *

First Name Last Name
Request Date *

Month Day Year
Date
Request Time *

Hour Minutes

AM/PM Option
Requestor Name *

First Name Last Name
Requestor Phone Number *
If unknown, enter "(000) 000-0000"
Requestor Type: *

Why was evaluation requested? *
Admission Date: *

Month Day Year
Date
Evaluator Name: *

First Name Last Name
Evaluator ID#: *
Evaluator Phone: *
Please enter a valid phone number.
Evaluation Date: *

Month Day Year
Date
Evaluation Time: *

Hour Minutes

AM/PM Option
Primary Referral Source: *
Evaluation Location: *
Living Situation: *

Homeless Staffed Facility Independent N/A Other
Lives with minor children? *

Yes No N/A
Employment: *
If not in labor force, please give reason why: *

Emergency Contact Name: *

First Name Last Name
Emergency Contact Phone Number: *
If unknown, enter "(000) 000-0000"
Relationship to Client: *

Spouse Parent Other
Outpatient Agency: *
Agency Phone Number: *
If unknown, enter "(000) 000-0000"
Name of Outpatient Clinician: *

First Name Last Name
Date of Last/Next Visit: *

Month Day Year
Date
Name of Outpatient MD: *

First Name Last Name
Phone Number of Outpatient MD: *
If unknown, enter "(000) 000-0000"
Please list current medications: *
(Include name, dosage, frequency & last dose)

4. Active Suicidal Ideation with Some Intent to Act, Without Specific Plan

Active suicidal thoughts of killing oneself and subject reports having some intent to act on such thoughts, as opposed to "I have the thoughts, but I definitely will not do anything about them."
In the last month, have you had these thoughts and had some intention of acting on them? *

Yes No
If yes, please explain.
In your lifetime, have you had these thoughts and had some intention of acting on them? *

Yes No
If yes, please explain.
5. Active Suicidal Ideation with Specific Plan and Intent

Thoughts of killing onself with details of plan fully or partially worked out and subject has some intent to carry it out.
In the last month, have you started to work out or worked out the details of how to kill yourself? Do you intend to carry out this plan? *

Yes No
If yes, please explain.
In your lifetime, have you started to work out or worked out the details of how to kill yourself? Do you intend to carry out this plan? *

Yes No
If yes, please explain.

Interrupted Attempt

When the person is interrupted (by an outside circumstance) from starting the potentially self injurious act (if not for that, actually attempt would have occurred).
Overdose: Person has pills in hand, but is stopped from ingensting. Once they ingest any pills, this becomes an attempt rather than an interrupted attempt.

Shooting: Person has a gun pointed at self, gun is taken away by someone else, or is somehow prevented from pulling trigger. Once they pull the trigger, even if the gun fails to fire, it is an attempt.

Jumping: Person is poised to jump, is grabbed and taken down from ledge.

Hanging: Person has noose around neck, but has not yet started to hang - is stopped from doing so.
In the last three months, has there been a time when you started to do something to end your life, but someone or something stopped you before you actually did anything? *

Yes No N/A
If yes, please describe
How many total attempts? *
In your lifetime, has there been a time when you started to do something to end your life, but someone or something stopped you before you actually did anything? *

Yes No
If yes, please describe
How many total attempts? *
Aborted or Self-Interrupted Attempt

When a person begins to take steps toward making a suicide attempt, but stops themselves before they actually have engaged in any self-destructive behavior. Examples are similar to interrupted attempts, except that the individual stops him/herself, instead of being stopped by something else.
In the last three months, has there been a time when you started to do something to try to end your life, but you stopped yourself before you actually did anything? *

Yes No
If yes, please describe
How many total attempts? *
In your lifetime, has there been a time when you started to do something to try to end your life, but you stopped yourself before you actually did anything? *

Yes No
If yes, please describe
How many total attempts? *

Preparatory Acts or Behavior

Acts or preparation towards imminently making a suicide attempt. This can include anything beyond a verbalization or thought, such as assembling a specific method (e.g. buying pulls, purchasing a gun) or preparing for one's death by suicide (e.g. giving things away, writing a suicide note).
In the last three months, have you taken any steps towards making a suicide attempt or preparing to kill yourself (such as collecting pills, getting a gun, giving valuables away or writing a suicide note)? *

Yes No N/A
If yes, please describe
In your lifetime, have you taken any steps towards making a suicide attempt or preparing to kill yourself (such as collecting pills, getting a gun, giving valuables away or writing a suicide note)? *

Yes No N/A
If yes, please describe
Suicidal Behavior
Suicidal behavior was present during this assessment period? *

Yes No N/A
Actual Lethality/Medical Damage:

0 - No physicial damage or very minor physical damage (e.g. surface scratches).

1 - Minor physical damage (e.g. lethargic speech; first-degree burns; mild bleeding; sprains).

2 - Moderate physical damage; medical attention needed (e.g. conscious but sleepy, somewhat responsive; second-degree burns; bleeding of major vessel).

3 - Moderately severe physical damage; medical hispitalization and likely intensive care required (e.g. comatose with reflectes intact; third-degree burnms less than 20% body; extensive blood loss, but can recover; major fractures).

4 - Severe physical damage; medical hospitalization with intesive care required (e.g. comatose without reflexes; third-degree burns over 20% of body; extensive blood loss with usntable vital signs; major damage to a vital area).

5 - Death.
Most Recent Attempt Date: *

Month Day Year
If unknown, enter "01-01-1000"
Lethality Code: *
Most Lethal Attempt Date: *

Month Day Year
If unknown, enter "01-01-1000"
Lethality Code: *
Initial/First Attempt Date: *

Month Day Year
If unknown, enter "01-01-1000"
Lethality Code: *

Potential Lethality (Only answer of actual lethality = 0)

Likely lethality of actual attempt if no medical damage (the following examples, while having no actual medical damage, had potential for very serious lethality: Put gun in mouth and pulled trigger, but gun fails to fire so no medical damage; laying on train tracks with oncoming train, but pulled away before run over).
0 - Behavior not likely to result in injury.

1 - Behavior likely to result in injury, but not likely cause death.

2 - Behavior likely to result in death, despite available medical care.
Most Recent Attempt Date: *

Month Day Year
If unknown, enter "01-01-1000"
Lethality Code: *
Most Lethal Attempt Date: *

Month Day Year
If unknown, enter "01-01-1000"
Lethality Code: *
Initial/First Attempt Date: *

Month Day Year
If unknown, enter "01-01-1000"
Lethality Code: *
Signature of Clinician *

Clear
Date *

Month Day Year
Date
Agency receiving form: *
Should be Empty:

Mobile Crisis Evaluation Form

Insurance Information

Mental Status

Observation:

Examination

Presenting Symptoms

Individualized Risk Indicators

Violence

Diagnosis

Consumer 48 Hour Reassessment Follow-Up

Mobile Columbia Suicide Scale

Suicidal Ideation

Intensity of Ideation

Frequency

Duration

Controllability

Deterrents

Reasons for Ideation

Suicidal Behavior

Interrupted Attempt

Aborted or Self-Interrupted Attempt

Preparatory Acts or Behavior

Suicidal Behavior

Potential Lethality (Only answer of actual lethality = 0)