Suicide Prevention Crisis Intervention Report
1. Client Information
Full Name
Age
Gender
Date & Time of Report
Contact Information
2. Referral Source
Who referred the client?
3. Presenting Situation
Summary of client's current crisis
Current risk factors (e.g., access to means, past attempts, self-harm)
Warning signs observed/reported
4. Assessment
Current mental state (mood, behavior, appearance)
Level of suicidal intent
Protective factors
Immediate concerns
5. Intervention
Interventions performed
Resources/contacted services
6. Safety Plan
Summary of safety plan
Support persons involved
7. Follow-Up
Recommendations
Follow-up arrangements
Report compiled by
Date