SCCS Mobile Crisis Adult Evaluation Form w/ Columbia

Mobile Crisis Adult Evaluation Form

South Central Crisis Service
Client Name*

First NameLast Name
Request Date*

MonthDayYear
Date
Request Time*

Hour Minutes

AM/PM Option
Requestor Name*

First NameLast Name
Requestor Phone Number*
If unknown, enter "(000) 000-0000"
Requestor Type:*
Why was evaluation requested?*
Admission Date:*

MonthDayYear
Date
Evaluator Name:*

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

MonthDayYear
Date
Evaluation Time:*

Hour Minutes

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

HomelessStaffed FacilityIndependentN/AOther
Lives with minor children?*

YesNoN/A
Employment:*
If not in labor force, please give reason why:*
Emergency Contact Name:*

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

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

First NameLast Name
Date of Last/Next Visit:*

MonthDayYear
Date
Name of Outpatient MD:*

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

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Client Social Security Number:
If no Social Security Number given, please give reason:

UnknownNot CollectedClient Refused
Client Date of Birth:

MonthDayYear
If no date of birth given, please give reason:

UnknownNot CollectedClient Refused
Gender:*

MaleFemaleUnknownOther
Client Marital Status:*

Language (Check one Primary, and check Secondary languages as needed):*

	Primary	Secondary
Cantonese
English
French
Greek
Haitian Creole
Italian
Japanese
Laotian
Latvian
Mandarin
Polish
Portugese
Russian
Sign Language
Spanish
Vietnamese
Other

Religion:*
Ethnic Origin (Choose only one):*
Race (Check all appropriate boxes):*

American Indian/Native AlaskanAsianBlack/African AmericanNative Hawaiian/Other Pacific IslanderWhite/CaucasianUnknownOther
Veteran:*

YesNoUnknown
Military Start Date:

MonthDayYear
If unknown, enter "01-01-1000"
Military End Date:

MonthDayYear
If unknown, enter "01-01-1000"
Pregnancy Status:*

YesNoUnknown
Tobacco Use:*

YesNoUnknown
Insurance Information

Insurance Types*

	Type 1
No Health Insurance
Other Private Insurance/HMO (Any 3rd party payor including Medicaid HMP, BC/BS, United Health Care, etc.)
Medicare
Champus (U.S. Military)
Medicaid
Managed Medicaid (Managed Care or HMO model)
SAGA-GA (State Administered General Assistance)
ATR (Access to Recovery)
Self Pay
Other
Unknown

Type 1 Policy Number:
If unknown, enter "unknown"
Type 1 Start Date:

MonthDayYear
If unknown, enter "01-01-1000"
Type 1 End Date:

MonthDayYear
If unknown, enter "01-01-1000"
Type 2 Policy Number:
If unknown, enter "unknown"
Type 2 Start Date:

MonthDayYear
If unknown, enter "01-01-1000"
Type 2 End Date:

MonthDayYear
If unknown, enter "01-01-1000"
Mental Status
Observation:
Hygiene:*

AppropriateAdequateMalodorousCleanN/A
Grooming:*

NeatUnkemptTattoosPiercingsLong FingernailsN/A
Clothing:*

AppropriateCasualProvocativeEccentricN/A
Relatedness:*

PleasantDistractedDemandingOpenConversantSillyImpulsiveGrandioseSuspicious/GuardedEvasiveHostileEngagingSarcasticIrritableCooperativeIntrusiveAggressiveProvocativeDefensiveN/A
Eye Contact:*

SteadyAversiveFleetingIntenseN/A
Speech Quality:*

ClearSlurredQuietLoudNon-Responsive/MuteN/A
Speech Rate & Energy:*

NormalTalkativePressuredExpansiveVerboseSlowHaltingSparse/AlogiaSlow Response TimeExcessiveN/A
Movement/Activity Level*

Steady/WNLFidgetingOveractiveRestlessUnable to Remain SeatedSlowedSlumpedCarefulUncoordinatedRepetitiveTicsShakingTremorJerkyPosturingPurposefulStiffTenseN/A
Ambulation:*

Normal GaitUnsteadyWalkerWheelchairN/A
Attention/Concentration:*

Intact enough to enable assessmentNotable deficitsN/A
Memory:*

Intact enough to enable assessmentNotable deficitsN/A
Insight:*

Substantially limitedPartialFullN/A
Judgement:*

PoorGuardedFairReasonableGoodN/A
Impulse Control:*

PoorGuardedFairReasonableGoodN/A
Examination
Client declined to respond fully to examination
Orientation:*

PersonPlacePrecise dateApproximate dateWeek DaySituationClient declined direct assessmentN/A
Estimated Intellectual Functioning:*

At least averageLikely below averageUnable to estimateEstablished intellectual impairmentN/A
Reported Mood (Quote client) :*
Affect:*

Congruent with patient reported moodIncongruent with patient reported moodLabileBlunt/ConstrictedIrritableFlatAnxiousDetachedSteadyFull RangeBizarreVariableN/A
Presenting Symptoms
Depression:*

DysphoriaAnhendoniaSleepLibidoAppetitePessimismHopelessWorthlessTearfulExcess GuiltNoneN/A
Mania:*

Increased energyRacing thoughtsRapid speechIncreased activityDecrease in sleepIncrease in impulsivityPleasure SeekingNoneN/A
Anxiety/Panic (Physical):*

Increase in heart rateNauseaDizzySweatyShort BreathChest PainTinglyClammyN/A
Anxiety/Panic (Behavioral):*

Shaky/TremblingRestlessRigidityN/A
Anxiety/Panic (Cognitive):*

Worry/Ruminate/CatastrophizeFear (General)Fear of deathDesire to escapeIndecisiveFear of panicN/A
Anxiety/Panic (Other):*

PhobiaNoneN/A
Psychosis Thought Organization*

Goal Directed/LinearLogical/RelevantFlight of IdeasIrrelevantPersonalizedLooseCircumstanstialTangentialBlockingImpoverished/Vague/SparseN/A
Compulsion*

ObsessionsRitualsAbsorbs TimeDiscomfort if not completedCountingCheckingContaminationNoneN/A
Thought Content (Hallucinations):*

AuditoryCommandDerogatoryTactile/Olfactory/TasteVisualNoneN/A
Thought Content (Delusions):*

PersecutoryBizarreRomantic/SexualSomaticBeing controlledIdeas of referenceGrandioseMagical thinkingThought insertionThought broadcastingSomatic preoccupationNone (no symptoms)N/A
Eating Disorder:*

BingeingPurgingRestrictingEating non-food itemsNoneN/A
Trauma*

HyperarousalHypervigilanceDissociationFlashbacksNightmaresDepersonalizationAvoidanceNoneN/A
Substance Abuse:*

Slurred speechReported useSmell of alcoholPoor coordinationAppears intoxicatedPossible withdrawalNoneN/A
Other:*

Unable to care for selfWeight loss (severe)ConfabulationUnknownNone (No symptoms)Other
Individualized Risk Indicators
Client specific prodromal indicators of decompensation (Please specify):*
Out of character behaviors (Please specify):*
Recurrent/current/anticipated stressors (Please specify):*
Violence
Has there been any violent behaviors reported:*

YesNoN/A
Reported by:

PatientCollateral Source
Name & Relationship of Collateral Source:

Homicidal*

	Today + Yesterday	7 Days	Prior to Last 7 Days	Denied	Unable to Assess
Thoughts
Behavior
Plans
Serious Threats

Assaultive/Aggressive*

	Today + Yesterday	7 Days	Prior to Last 7 Days	Denied	Unable to Assess
Thoughts
Behavior
Plans
Serious Threats
Non-Accidental Property Destruction
Access to Firearms/Weapons

Fire-setting*

	Today + Yesterday	7 Days	Prior to Last 7 Days	Denied	Unable to Assess
Thoughts
Behavior
Plans
Serious Threats

Risky/Aggressive Sexual Behavior*

	Today + Yesterday	7 Days	Prior to Last 7 Days	Denied	Unable to Assess
Thoughts
Behavior
Accused of Stalking or Sexual Assault
Restraining Order Against Them
Impaired Impulse Control
Behavior Substantially Influenced by Delusion

Verbal aggression or substantial irritability during interview?*

YesNoN/A
Aggressive ideation toward others:*

None expressedToward individualGroupIn general/GlobalN/A
Descriptions of Affirmative Responses, if applicable:*
Past Psychiatric History*

NoneInpatientOutpatientMany EpisodesN/A
Please describe past history (noted above):

Treatment Related Risk Indicators*

	Yes	No	Unknown
Declining to participate in lower level of care
Not taking medication as prescribed
Declining to fully cooperate with assessment
Has not kept recent appointments

Substance Abuse*

AlcoholCannabisCocaine (Crack)Cocaine (Powder)HallucinogensInhalantsMethadone (Not prescribed)Opiates (Heroin)Opiates (Other)Over the Counter DrugsPCP related drugsSedatives (Barbituates)Sedatives (Other)Stimulants (Amphetamine or Methamphetamine)Stimulants (Other)Tranquilizers (Benzodiazepines)Tranquilizers (Other)NoneN/AOther
Substance Abuse Amount, Duration, Pattern, and Last Use:*
Legal Issues:*

YesNo
Is yes, please describe:*
Diagnosis
Effective Date of Diagnosis*

MonthDayYear
If unknown, enter "01-01-1000"
Diagnosis Type (Check all that apply)*

Inadequate InformationNo Significant Psych or Substance AbusePsych Substance AbusePsychiatric OnlySubstance Abuse OnlyN/A
Axis I Diagnosis*
If no diagnosis, enter "N/A"
Description*
If no diagnosis, enter "N/A"
Axis II Diagnosis*
If no diagnosis, enter "N/A"
Description*
If no diagnosis, enter "N/A"
Axis III Diagnosis*
If no diagnosis, enter "N/A"
Description*
If no diagnosis, enter "N/A"

Axis IV*

	Yes	No
1) Problems with Primary Support Group
2) Problems Related to the Social Environment
3) Educational Problems
4) Occupational Problems
5) Housing Problems
6) Economic Problems
7) Problems with Access to Health Services
8) Problems Related to the Legal System/Crime
9) Other Psychosocial and Environmental Problems

Axis V - GAF Score *
(Enter 1-100)
Police Department (City/Town):*
Disclosures:*

DCFPolice DepartmentN/AOther
Name of Disclosure:
CIT Clinician Present:*

YesNo
Name of Clinician:
Transport to ED:*

N/APoliceClinicianVoluntaryAmbulance
Arrest Made:*

NoYesPendingN/A
Most Serious Charge Type:*

FelonyMisdemeanorOther Charge TypeNoneN/A
Disposition Referral:*

Crisis/Respite BedCrisis Follow-UpVeteran's AdminstrationDept of Child & Families (DCF)Dept of Developmental Services (DDS)No Referral (Client Refused)No Referral (Services Not Needed)No Referral (Other)Medical InpatientResidentialCase ManagementCommunity Support Program (CSP)Assertive Community TreatmentOutpatient (OP)Recovery SupportsPartial Hospital Program (PHP)Psych InpatientEmergency Department
Disposition Date:*

MonthDayYear
Date
Disposition Time:*

Hour Minutes

AM/PM Option
Total Time:*
Total minutes
Final Intervention & Plan (Include additional contacts with phone numbers):*
Facility Name:*
Consumer 48 Hour Reassessment Follow-Up
Time:*

Hour Minutes

AM/PM Option
Agency:*
Type of Follow-Up*

TelephonicFace-to-faceN/A
HIPPA Consent Action:*

NPP Consent SignedNot Completed
If not completed, explain:*

Individual refusedEmergency treatment situationIncompetence or medical reasonOther
Screening Tools (MH/SA):*

Screening Tools SignedNot Completed
If not completed, explain:*

Individual refusedEmergency treatment situationIncompetence or medical reasonOther
Clinical Assessment Narrative:*
Mobile Columbia Suicide Scale
Columbia Suicide Severity Rating Scale:*

Performed - Refer to clinical assessment narrativeNot performed as client was transported to EDNot performed as no past or present suicidal ideation
Suicidal Ideation

Ask questions 1 and 2. If both are negative, proceed to "Suicidal Behavior" section. If the answer to question 2 is "Yes," ask questions 3, 4, and 5. If the answer to question 1 and/or 2 is "Yes," complete "Intensity of Ideation section below.
1. Wish to be Dead

Subject endorses thoughts about a wish to be dead or not alive anymore, or wish to fall asleep and not wake up.
In the past month, have you wished you were dead or wished you could go to sleep and not wake up?*

YesNo
If yes, please explain.
In your lifetime, have you wished you were dead or wished you could go to sleep and not wake up?*

YesNo
If yes, please explain.
2. Non-Specific Active Suicidal Thoughts

General non-specific thoughts of wanting to end one's life/commit suicide (e.g. "I've thought about killing myself") without thoughts of ways to kill oneself/associated methods, intent, or plan during the assessment period.
In the past month, have you had any thoughts of killing yourself?*

YesNo
If yes, please explain.
In your lifetime, have you actually had any thoughts of killing yourself?*

YesNo
If yes, please explain.
3. Active Suicidal Ideation with Any Methods (Not Plan) Without Intent to Act

Subject endorses thoughts of suicide and has thought of at least one method during the assessment period. This is different than a specific plan with time, place, or method details worked out (e.g. thought of method to kill self, but not a specific plan). Includes person who would say, "I thought about taking an overdose, but I never made a specific plan as to when, where, or how I would actually do it...and I would never go through with it."
In the last month, have you been thinking about how you might do this?*

YesNo
If yes, please explain.
In your lifetime, have you thought about how you might do this?*

YesNo
If yes, please explain.
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?*

YesNo
If yes, please explain.
In your lifetime, have you had these thoughts and had some intention of acting on them?*

YesNo
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?*

YesNo
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?*

YesNo
If yes, please explain.
Intensity of Ideation

The following features should be rated with respect to the most severe type of ideation (i.e. 1-5 from above, with 1 being the least severe and 5 being the most severe). Ask about time he/she was feeling the most suicidal.
Lifetime - Most Severe Ideation*
Type # 1-5
Description of Ideation*
Recent - Most Severe Ideation*
Type # 1-5
Description of Ideation*
Frequency
How many times have you had these thoughts?*

Less than once a weekOnce a week2-5 times a weekDaily or almost dailyMany times each dayN/A
Duration
When you have the thoughts, how long do they last?*

Fleeting - few seconds or minutesLess than 1 hour/some of the time1-4 hours/a lot of time4-8 hours/most of the dayMore than 8 hours/persistent or continuousN/A
Controllability
Could/can you stop thinking about killing yourself or wanting to die if you want to?*

Easily able to control thoughtsCan control thoughts with little difficultyCan control thoughts with some difficultyCan control thoughts with a lot of difficultyUnable to control thoughtsDoes not attempt to control thoughtsN/A
Deterrents
Are there things - anyone or anything (e.g. family, religion, pain of death) - that stopped you from wanting to die or acting on thoughts of committing suicide?*

Deterrents definitely stopped you from attempting suicideDeterrents probably stopped youUncertain that deterrents stopped youDeterrents most likely did not stop youDeterrents definitely did not stop youDoes not applyN/A
Reasons for Ideation
What sort of reasons did you have for thinking about wanting to die or killing yourself? Was it to end the pain or to stop the way you were feeling (in other words, you couldn't go on living with this pain or how you were feeling) or was it to get attention, revenge, or a reaction from others? Or both?*

Completely to get attention, revenge, or a reaction from othersMostly to get attention, revenge or a reaction from othersEqually to get attention, revenge, or a reaction from others and to end/stop the painMostly to end or stop the pain (you couldn't go on living with the pain or how you were feeling)Completely to end or stop the pain (you couldn't go on living with the pain or how you were feeling)Does not applyN/A
Suicidal Behavior

Check all that apply, as long as these are separate events, must as about all types
Actual Attempt

A potentially self-injurious act committed with at least some wish to die, as a result of act. Behavior was in part thought of as method to kill oneself. Intent does not have to be 100%. If there is any intent/desire to die associated with the act, then it can be considered an actual suicide attempt. There does not have to be any injury or harm, just the potential for injury or harm. If person pulls trigger while gun is in mouth, but gun is broken, so no injury results, this is considered an attempt.

Inferring Intent: Even if an individual denies intent/wish to die, it may be inferred clinically from the behavior or circumstanced. For example, a highly lethal act that is clearly not an accident so not other intent but suicide can be inferred (e.g. gunshot to head, jumping from window of a high floor/story). Also, if someone denies intent to die, but they thought that what they did could be lethal, intent may be inferred.
In the past 3 months, have you made a suicide attempt?*

YesNoN/A
How many total attempts?*
In your lifetime, have you made a suicide attempt?*

YesNoN/A
How many total attempts?*
In the past 3 months, have you done anything to harm yourself?*

YesNoN/A
In your lifetime, have you done anything to harm yourself?*

YesNoN/A
In the past 3 months, have you done anything dangerous where you could have died?*

YesNoN/A
In your lifetime, have you done anything dangerous where you could have died?*

YesNoN/A
What did you do?
Did you commit this act as a way to end your life?*

YesNoN/A
Did you want to die (even a little) when you committed this act?*

YesNoN/A
Were you trying to end your life when you committed this act?*

YesNoN/A
Did you think it was possible you could have died from committing this act?*

YesNoN/A
Did you do it purely for other reasons/without ANY intention of killing yourself (like to relieve stress, feel better, get sympathy, or get something else to happen)?*

YesNoN/A
If yes, please describe
In the past three months, has the subject engaged in non-suicidal, self-injurious behavior?*

YesNoN/A
In his/her lifetime, has the subject engaged in non-suicidal, self-injurious behavior?*

YesNoN/A
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?*

YesNoN/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?*

YesNo
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?*

YesNo
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?*

YesNo
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)?*

YesNoN/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)?*

YesNoN/A
If yes, please describe
Suicidal Behavior
Suicidal behavior was present during this assessment period?*

YesNoN/A
Has the client ever attempted suicide?

YesNoUnknown
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:

MonthDayYear
If unknown, enter "01-01-1000"
Lethality Code:
Most Lethal Attempt Date:

MonthDayYear
If unknown, enter "01-01-1000"
Lethality Code:
Initial/First Attempt Date:

MonthDayYear
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:

MonthDayYear
If unknown, enter "01-01-1000"
Lethality Code:
Most Lethal Attempt Date:

MonthDayYear
If unknown, enter "01-01-1000"
Lethality Code:
Initial/First Attempt Date:

MonthDayYear
If unknown, enter "01-01-1000"
Lethality Code:
Action Taken (choose one)*

No FindingsConsulted SupervisorSent to Hospital for Evaluation
Signature of Clinician*

Clear
Date*

MonthDayYear
Date
Agency receiving form:*
Should be Empty:

Mobile Crisis Adult 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)