Survivor Crisis Assessment Questionnaire
Personal Information
Full Name
Date of Birth
Contact Information
Date of Assessment
Presenting Problem
Please describe the reason for your visit:
History and Background
Brief history of crisis event(s):
Support systems (family, friends, professionals):
Current Situation
Current living situation:
Immediate needs:
Risk Assessment
Risk of self-harm
None
Low
Moderate
High
Risk to others
None
Low
Moderate
High
Comments on risk factors:
Mental & Physical Health
Describe current mental health symptoms:
Describe current physical health symptoms:
Resources & Coping
Personal strengths/resources identified:
Coping strategies used:
Action Plan
Steps to be taken:
Additional Notes: