Child Client Alert Form (17 years & younger)

Child Client Alert Form (17 years & younger)

Version 1.0 | South Central Crisis Service
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Thank you.
- Please complete this forms in its entirety.
- All submissions received after 5pm will not be available to the SCCS clinicians until the next business day.
- If after 5pm and there is a crisis, page SCCS on-call clinician at (800) 973-2659 for immediate response.
Date:*

MonthDayYear
Date
Client Name:*

First NameLast Name
Age:
If unknown, enter '00'
Date of Birth:

MonthDayYear
If unknown, enter "01-01-1000."
Gender:

MaleFemaleOther
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of Guardian:

First NameLast Name
Relationship to Client:
Guardian's Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Agency:
If Unaffiliated/Other, please explain:
Psychiatrist:

First NameLast Name
Clinician:

First NameLast Name
Phone Number:
If unknown, enter "(000) 000-0000"
Psychiatric Diagnosis:
Medical Diagnosis:
Medications/Dosages (Psychiatric):
Medications/Dosages (Other):
Pharmacy Name:
Phone Number:
If unknown, enter "(000) 000-0000"
DCF Involvement?

YesNo
If yes, please describe:
Legal Issues?

YesNo
If yes, please describe:
Current Risk Factors and History of Risky Behaviors/Symptoms (Identify prior violence, prior suicide attempts, trauma, and substance abuse issues):
Please assist crisis staff in identifying what therapeutic interventions/techniques would be helpful to use if client calls. Please be specific.
Name of Person Completing this Form:*
Should be Empty: