SCCS Mobile Crisis Adult Evaluation Form w/ Columbia

Mobile Crisis Adult 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)
Client Address: *

Street Address

Street Address Line 2

City State / Province

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

Unknown Not Collected Client Refused
Client Date of Birth:

Month Day Year
If no date of birth given, please give reason:

Unknown Not Collected Client Refused
Gender: *

Male Female Unknown Other
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 Alaskan Asian Black/African American Native Hawaiian/Other Pacific Islander White/Caucasian Unknown Other
Veteran: *

Yes No Unknown
Military Start Date:

Month Day Year
If unknown, enter "01-01-1000"
Military End Date:

Month Day Year
If unknown, enter "01-01-1000"
Pregnancy Status: *

Yes No Unknown
Tobacco Use: *

Yes No Unknown
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:

Month Day Year
If unknown, enter "01-01-1000"
Type 1 End Date:

Month Day Year
If unknown, enter "01-01-1000"
Type 2 Policy Number:
If unknown, enter "unknown"
Type 2 Start Date:

Month Day Year
If unknown, enter "01-01-1000"
Type 2 End Date:

Month Day Year
If unknown, enter "01-01-1000"
Mental Status
Observation:
Hygiene: *

Appropriate Adequate Malodorous Clean N/A
Grooming: *

Neat Unkempt Tattoos Piercings Long Fingernails N/A
Clothing: *

Appropriate Casual Provocative Eccentric N/A
Relatedness: *

Pleasant Distracted Demanding Open Conversant Silly Impulsive Grandiose Suspicious/Guarded Evasive Hostile Engaging Sarcastic Irritable Cooperative Intrusive Aggressive Provocative Defensive N/A
Eye Contact: *

Steady Aversive Fleeting Intense N/A
Speech Quality: *

Clear Slurred Quiet Loud Non-Responsive/Mute N/A
Speech Rate & Energy: *

Normal Talkative Pressured Expansive Verbose Slow Halting Sparse/Alogia Slow Response Time Excessive N/A
Movement/Activity Level *

Steady/WNL Fidgeting Overactive Restless Unable to Remain Seated Slowed Slumped Careful Uncoordinated Repetitive Tics Shaking Tremor Jerky Posturing Purposeful Stiff Tense N/A
Ambulation: *

Normal Gait Unsteady Walker Wheelchair N/A
Attention/Concentration: *

Intact enough to enable assessment Notable deficits N/A
Memory: *

Intact enough to enable assessment Notable deficits N/A
Insight: *

Substantially limited Partial Full N/A
Judgement: *

Poor Guarded Fair Reasonable Good N/A
Impulse Control: *

Poor Guarded Fair Reasonable Good N/A
Examination
Client declined to respond fully to examination
Orientation: *

Person Place Precise date Approximate date Week Day Situation Client declined direct assessment N/A
Estimated Intellectual Functioning: *

At least average Likely below average Unable to estimate Established intellectual impairment N/A
Reported Mood (Quote client) : *
Affect: *

Congruent with patient reported mood Incongruent with patient reported mood Labile Blunt/Constricted Irritable Flat Anxious Detached Steady Full Range Bizarre Variable N/A
Presenting Symptoms
Depression: *

Dysphoria Anhendonia Sleep Libido Appetite Pessimism Hopeless Worthless Tearful Excess Guilt None N/A
Mania: *

Increased energy Racing thoughts Rapid speech Increased activity Decrease in sleep Increase in impulsivity Pleasure Seeking None N/A
Anxiety/Panic (Physical): *

Increase in heart rate Nausea Dizzy Sweaty Short Breath Chest Pain Tingly Clammy N/A
Anxiety/Panic (Behavioral): *

Shaky/Trembling Restless Rigidity N/A
Anxiety/Panic (Cognitive): *

Worry/Ruminate/Catastrophize Fear (General) Fear of death Desire to escape Indecisive Fear of panic N/A
Anxiety/Panic (Other): *

Phobia None N/A
Psychosis Thought Organization *

Goal Directed/Linear Logical/Relevant Flight of Ideas Irrelevant Personalized Loose Circumstanstial Tangential Blocking Impoverished/Vague/Sparse N/A
Compulsion *

Obsessions Rituals Absorbs Time Discomfort if not completed Counting Checking Contamination None N/A
Thought Content (Hallucinations): *

Auditory Command Derogatory Tactile/Olfactory/Taste Visual None N/A
Thought Content (Delusions): *

Persecutory Bizarre Romantic/Sexual Somatic Being controlled Ideas of reference Grandiose Magical thinking Thought insertion Thought broadcasting Somatic preoccupation None (no symptoms) N/A
Eating Disorder: *

Bingeing Purging Restricting Eating non-food items None N/A
Trauma *

Hyperarousal Hypervigilance Dissociation Flashbacks Nightmares Depersonalization Avoidance None N/A
Substance Abuse: *

Slurred speech Reported use Smell of alcohol Poor coordination Appears intoxicated Possible withdrawal None N/A
Other: *

Unable to care for self Weight loss (severe) Confabulation Unknown None (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: *

Yes No N/A
Reported by:

Patient Collateral 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? *

Yes No N/A
Aggressive ideation toward others: *

None expressed Toward individual Group In general/Global N/A
Descriptions of Affirmative Responses, if applicable: *
Past Psychiatric History *

None Inpatient Outpatient Many Episodes N/A
Please describe past history (noted above):

Treatment Related Risk Indicators *

Yes

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 *

Alcohol Cannabis Cocaine (Crack) Cocaine (Powder) Hallucinogens Inhalants Methadone (Not prescribed) Opiates (Heroin) Opiates (Other) Over the Counter Drugs PCP related drugs Sedatives (Barbituates) Sedatives (Other) Stimulants (Amphetamine or Methamphetamine) Stimulants (Other) Tranquilizers (Benzodiazepines) Tranquilizers (Other) None N/A Other
Substance Abuse Amount, Duration, Pattern, and Last Use: *
Legal Issues: *

Yes No
Is yes, please describe: *
Diagnosis
Effective Date of Diagnosis *

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

Inadequate Information No Significant Psych or Substance Abuse Psych Substance Abuse Psychiatric Only Substance Abuse Only N/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

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: *

DCF Police Department N/A Other
Name of Disclosure:
CIT Clinician Present: *

Yes No
Name of Clinician:
Transport to ED: *

N/A Police Clinician Voluntary Ambulance
Arrest Made: *

No Yes Pending N/A
Most Serious Charge Type: *

Felony Misdemeanor Other Charge Type None N/A
Disposition Referral: *

Crisis/Respite Bed Crisis Follow-Up Veteran's Adminstration Dept of Child & Families (DCF) Dept of Developmental Services (DDS) No Referral (Client Refused) No Referral (Services Not Needed) No Referral (Other) Medical Inpatient Residential Case Management Community Support Program (CSP) Assertive Community Treatment Outpatient (OP) Recovery Supports Partial Hospital Program (PHP) Psych Inpatient Emergency Department
Disposition Date: *

Month Day Year
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 *

Telephonic Face-to-face N/A
HIPPA Consent Action: *

NPP Consent Signed Not Completed
If not completed, explain: *

Individual refused Emergency treatment situation Incompetence or medical reason Other
Screening Tools (MH/SA): *

Screening Tools Signed Not Completed
If not completed, explain: *

Individual refused Emergency treatment situation Incompetence or medical reason Other
Clinical Assessment Narrative: *
Mobile Columbia Suicide Scale
Columbia Suicide Severity Rating Scale: *

Performed - Refer to clinical assessment narrative Not performed as client was transported to ED Not 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? *

Yes No
If yes, please explain.
In your lifetime, have you wished you were dead or wished you could go to sleep and not wake up? *

Yes No
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? *

Yes No
If yes, please explain.
In your lifetime, have you actually had any thoughts of killing yourself? *

Yes No
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? *

Yes No
If yes, please explain.
In your lifetime, have you thought about how you might do this? *

Yes No
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? *

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.
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 week Once a week 2-5 times a week Daily or almost daily Many times each day N/A
Duration
When you have the thoughts, how long do they last? *

Fleeting - few seconds or minutes Less than 1 hour/some of the time 1-4 hours/a lot of time 4-8 hours/most of the day More than 8 hours/persistent or continuous N/A
Controllability
Could/can you stop thinking about killing yourself or wanting to die if you want to? *

Easily able to control thoughts Can control thoughts with little difficulty Can control thoughts with some difficulty Can control thoughts with a lot of difficulty Unable to control thoughts Does not attempt to control thoughts N/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 suicide Deterrents probably stopped you Uncertain that deterrents stopped you Deterrents most likely did not stop you Deterrents definitely did not stop you Does not apply N/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 others Mostly to get attention, revenge or a reaction from others Equally to get attention, revenge, or a reaction from others and to end/stop the pain Mostly 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 apply N/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? *

Yes No N/A
How many total attempts? *
In your lifetime, have you made a suicide attempt? *

Yes No N/A
How many total attempts? *
In the past 3 months, have you done anything to harm yourself? *

Yes No N/A
In your lifetime, have you done anything to harm yourself? *

Yes No N/A
In the past 3 months, have you done anything dangerous where you could have died? *

Yes No N/A
In your lifetime, have you done anything dangerous where you could have died? *

Yes No N/A
What did you do?
Did you commit this act as a way to end your life? *

Yes No N/A
Did you want to die (even a little) when you committed this act? *

Yes No N/A
Were you trying to end your life when you committed this act? *

Yes No N/A
Did you think it was possible you could have died from committing this act? *

Yes No N/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)? *

Yes No N/A
If yes, please describe
In the past three months, has the subject engaged in non-suicidal, self-injurious behavior? *

Yes No N/A
In his/her lifetime, has the subject engaged in non-suicidal, self-injurious behavior? *

Yes No N/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? *

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: *
Action Taken (choose one) *

No Findings Consulted Supervisor Sent to Hospital for Evaluation
Signature of Clinician *

Clear
Date *

Month Day Year
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)