Date of Service
Location/Mode: In-Office / Telehealth / Phone

Crisis Presentation & Clinical Status

• Precipitating Event(s): acute stressor prompting immediate attention
• Client’s Stated Needs: in client’s own words

Current Medications & Medical Status

Included when stated and relevant to clinical presentation and risk. 

• Current psychiatric/other medications, recent changes, non-adherence
• Relevant medical diagnoses relevant to crisis presentation

Substance Use

Included when substance use evident

• Substances, frequency, most recent use and the link between use and crisis

Mental Status Examination

• Behavior: Describe client’s activity level and notable behaviors.
• Speech: Comment if speech was unusually fast or slow.
• Mood: Record client’s reported emotional state (client’s own words).
• Affect: Describe client’s emotional expression and range.
• Thoughts: Note thought processes and content, including any abnormalities.
• Perceptions: Record any hallucinations or sensory issues.
• Cognition: Describe memory, orientation, concentration, comprehension.
• Insight: Comment on client’s understanding of their condition.
• Judgment: Describe client’s decision-making ability.

Risk Assessment

Current Risk Concerns

• List only categories identified this session (suicidal ideation, homicidal ideation, violence/aggression, auditory hallucinations, visual hallucinations, non-suicidal self-injurious behavior, intimate partner violence, other)

Print “None documented” if no concerns are present

Details for Present Risk

• Suicidal ideation — passive vs active, frequency/duration, method, intent, plan, timeline, preparatory behavior, access to lethal means; each element stated as present with detail, denied, or not documented
• Homicidal ideation — passive vs active, target, method, intent, plan, preparatory behavior, access to lethal means; each element stated as present with detail, denied, or not documented
• Violence/aggression — nature, severity, triggers, frequency, target (specific vs general); distinguished from homicidal ideation
• Non-suicidal self-injury — nature, method, frequency, most recent occurrence; distinguished from suicidal behavior
• Hallucinations — type, content, frequency, impact; command hallucination content and compliance/resistance if present
• Intimate partner violence — explicitly stated or observed safety concerns within the relationship
• Other — additional concerns not captured above, including mandatory reporting concerns (child, elder, or dependent adult abuse/neglect) and the relevant category
• Direct client/clinician quotes included only where documented, attributed as “client reported” or “clinician observed”
• Psychosocial risk factors — social isolation, bullying, financial difficulty, legal issues, bereavement, indicators of grave disability, other stressors

Print “No risk concerns identified” if the Current Risk Concerns list was empty

History of Risk Behavior

• Previous suicide attempts — number, method, date of most recent, medical lethality where documented
• Previous non-suicidal self-injury
• Previous psychiatric hospitalizations related to risk
• History of violence or aggression toward others
• Each item stated as present with detail, denied, or not documented

Print “History of risk behavior: Not documented” if none of the above are documented

Psychometric Assessment Results

Included if administered

• Assessment name, date, result/score, severity, clinical interpretation

Crisis Interventions & Safety Planning

• De-escalation / Grounding Techniques: specific therapeutic actions used to lower immediate distress
• Lethal-Means Counseling: steps taken to secure the environment or separate the client from means
• Collateral & Coordination Support: consultation with family, psychiatry, mobile crisis teams, or emergency services
• Collaborative Safety Plan Updates: warning signs, internal coping tools, crisis hotlines, and distribution of the physical/digital safety plan
• Protective Factors: personal strengths, resources, reasons for living, belief systems, coping skills, or environmental factors that reduce risk
• Client’s Immediate Response to Interventions: client’s evidenced physiological, behavioral, and verbal response to the de-escalation techniques, directives, or safety protocols used

Medical Necessity / Clinical Justification

• Acute risk/instability requiring intensive intervention over routine care and why it was needed to mitigate risk, prevent escalation to a higher level of care

Disposition & Future Care Plan

• Immediate Disposition: brief statement on level of care and intervention indicated (outpatient with safety plan, inpatient, transfer to higher level of care, or voluntary/involuntary hospitalization)
• Follow-Up Timeline: date and time of next mandatory wellness check or subsequent session
• Homework / Out-of-Session Support: any worksheets or safety trackers assigned