9070AD Crisis Screening Report

Coventry School Committee Policy #: 9070AD

A crisis screening report will be completed in a timely manner by the person(s) initially aware of the situation.

CRISIS SCREENING REPORT

COVENTRY PUBLIC SCHOOLS

UNIFIED LEARNING SUPPORT SERVICES

*Confidential*

Student_____________________________ Parent’s Name_____________________________

DOB__________ Age ______ Sex ______ Address___________________________________

School ___________ Grade _____ Phone (H) _________________ (W) __________________

Student referred by: ____________________________________________________________

____________________________________________________________________________

Recent suicidal gesture/ideation: __________________________________________________

_____________________________________________________________________________

Past suicidal gestures/ideation: ____________________________________________________

_____________________________________________________________________________

Suicide plan? ___ Describe: ______________________________________________________

_____________________________________________________________________________

Access to lethal means for plan? ___ Describe: ______________________________________

_____________________________________________________________________________

Substance abuse history? ________________________________________________________

_____________________________________________________________________________

Significant losses/anniversaries: ___ Describe: ______________________________________

_____________________________________________________________________________

Support system? ___ Describe: ___________________________________________________

_____________________________________________________________________________

Mental health diagnoses? ___ Describe: ___________________________________________

_____________________________________________________________________________

Abuse history (sexual, physical)? ___ Describe: _____________________________________

_____________________________________________________________________________

Level of self-regard? ___ Describe: _______________________________________________

_____________________________________________________________________________

Brief description of crisis:________________________________________________________

_____________________________________________________________________________

ACTIONS TAKEN

Not

Yes No Applicable Comments

Student contacted? ____ ____ ____ ________________________________

If yes, by whom?: ______________________________ Date/Time: _____________________

Parents contacted? ____ ____ ____ ________________________________

If yes, by whom?: _______________________________ Date/Time: _____________________

Guidance counselor informed? ____ ____ ____ ________________________________

If yes, then whom?: ____________________________ Date/Time: ____________________

School Social worker informed? ____ ____ ____ ________________________________

If yes, then whom?: _____________________________ Date/Time: _____________________

School nurse informed? ____ ____ ____ ________________________________

If yes, then whom?: ____________________________________________________________

Building administrator informed? ____ ____ ____ ________________________________

If yes, them whom?:____________________________ Date/Time: ______________________

Outside agency contacted? ____ ____ ____ ________________________________

Complete the following section if an outside agency is contacted.

a) Name of agency: __________________________________________________________

b) Date, time: ______________________________________________________________

c) Person contacting agency: ___________________________________________________

d) Person contacted: __________________________________________________________

e) Agency response: __________________________________________________________

Student released: ____ ____ ____ ________________________________

If yes, to whom?: _____________________________ Date/Time: ______________________

Recommendation(s)

Student _____________________________________________________________________

____________________________________________________________________________

Parents ______________________________________________________________________

____________________________________________________________________________

Other ______________________________________________________________________ ____________________________________________________________________________

________________________ _____________________

Person Completing Form/Date Building Administrator

CRISIS SCREENING FOLLOW-UP REPORT

COVENTRY PUBLIC SCHOOLS

UNIFIED LEARNING SUPPORT SERVICES

*Confidential*

Student_____________________________ Parent’s Name____________________________

DOB__________ Grade ______ Phone (H) _________________ (W) ___________________

School _______________________________

Brief description of follow-up if applicable:

____________________________________________________________________________

____________________________

Person Completing Form/Date