Crisis Intake Assessment Form
Client Information
Full Name
Date of Birth
Gender
Male
Female
Non-binary
Other
Contact Number
Address
Referral Details
Referred By
Referral Source
Self
Family
Agency
Other
Date of Intake
Presenting Crisis
Description of Crisis
Duration of Crisis
Immediate Risk (harm to self/others)
Yes
No
Unclear
Current Supports
Current Support System
Current Mental Health Providers
Medications
Assessment
Initial Assessment/Impressions
Immediate Needs/Interventions
Follow-Up Plan
Recommended Next Steps
Follow-Up Date
Assessor Name