Mental Health Crisis Intervention Assessment

Client Information

Full Name Date of Birth Date of Assessment Assessor Name

Presenting Problem

Presenting Complaint / Reason for Crisis

Risk Assessment

Risk of Self-Harm None Low Moderate High Suicidal Thoughts/Behavior None Thoughts Plans Attempts Risk of Harm to Others None Low Moderate High Risk Assessment Details

Mental Status Examination

Appearance/Behavior Mood/Affect Thought Process/Content Orientation/Insight/Judgment

Intervention & Plan

Interventions Provided Safety/Follow-Up Plan