Crisis Prevention/Intervention Plan

Volunteer Behavioral Health Care System
CRISIS PREVENTION / INTERVENTION PLAN
(Information from this form is to be entered into the VBHCS Electronic Health Record)
Field is required!
Field is required!
Name
Field is required!
Field is required!
Address
Field is required!
Field is required!
Medical Record #
Field is required!
Field is required!
Phone #
Field is required!
Field is required!
Directions to home
Field is required!
Field is required!
1. What are the first things (feelings/thoughts) you or others recognize which indicate your symptoms are getting worse?
Field is required!
Field is required!
2. What has helped me when I have felt this way before?
Field is required!
Field is required!
3. Things my family, friends or others can do to help me:
Field is required!
Field is required!
4. What particular mental health intervention(s) have been helpful in the past?
Field is required!
Field is required!
5. If necessary to be away from home, who would take care of my immediate needs such as children, pets, and other household needs (if applicable)?
Field is required!
Field is required!
Medical Information

If additional resources are necessary to manage your current symptoms, what is your preference for:
Field is required!
Field is required!
Primary Care Physician
Field is required!
Field is required!
Medical Hospital Preference
Field is required!
Field is required!
Psychiatric Hospital Preference
Field is required!
Field is required!
Phone #
Field is required!
Field is required!
Phone #
Field is required!
Field is required!
Phone #
Field is required!
Field is required!
Emergency Contact Information:
Field is required!
Field is required!
Name
Field is required!
Field is required!
Name
Field is required!
Field is required!
Relation
Field is required!
Field is required!
Relation
Field is required!
Field is required!
Phone #
Field is required!
Field is required!
Phone #
Field is required!
Field is required!
Support System Information:
Field is required!
Field is required!
Name
Field is required!
Field is required!
Name
Field is required!
Field is required!
Relation
Field is required!
Field is required!
Relation
Field is required!
Field is required!
Phone #
Field is required!
Field is required!
Phone #
Field is required!
Field is required!
Are Release of Information for emergency contact(s)/support system in client record?
  • - select Yes or No -
  • Yes
  • No
- select Yes or No -
Field is required!
Field is required!
If youu would like communications via phone, text or email, please provide the following:
Field is required!
Field is required!
Cell Phone Text
Field is required!
Field is required!
Cell Phone Call
Field is required!
Field is required!
Home/Land Line Phone
Field is required!
Field is required!
E-mail Address
Field is required!
Field is required!
Signature of Staff Completing:
Field is required!
Field is required!
Date
Field is required!
Field is required!
Submit