Crisis Intervention Intake Form
Client Information
First Name
Last Name
Date of Birth
Gender
Male
Female
Non-binary
Prefer not to say
Other
Phone
Email
Address
Emergency Contact
Name
Phone
Relationship
Referral Information
Referral Source
Referral Contact
Crisis Details
Reason for Crisis Intervention
Describe Current Situation
Are there immediate safety concerns?
Mental Health History
Mental Health Diagnosis (if any)
Previous Interventions/Treatment
Other Information
Additional Notes