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12- Crisis Training Material

June 11, 2024

Considerations for Counseling Referral Treatment and/or Follow-Up

Do you feel stressed out or under a lot of pressure?
Do you ever feel sad, hopeless, depressed, or anxious?
Do you feel safe at your home or residence?
Have you ever tried cigarettes, chewing tobacco, snuff, or dip?
During the past 30 days, did you use chewing tobacco, snuff, or dip?
Do you drink alcohol or use any other drugs?
Have you ever taken anabolic steroids or used any other performance supplement?
Have you ever taken any supplements to help you gain or lose weight or improve your performance?
Do you wear a seatbelt, use a helmet, and use condoms?

Consider reviewing Preparticipation Physical Evaluation History Form questions on cardiovascular symptoms (questions 5-12).

Abnormal findings must be referred to an appropriate specialist for further evaluation.

Forms:

Confidential Report for Designated Schoo Officials ONLY

Name of School DistrictName of School SiteStudent Name *FirstLastGradeSocial Security # on FileReferred By

HCIS
School Official

Name of School Official *FirstLastSignatureDateDate of IncicentDateTimeScreened By *FirstLastNon-Emergency Referral for Case Review

ReasonPlease Check all that apply

Reported under Penal Code Section 11169
Patient Emergency Team (PET)
Law Enforcement
Section 5585 HOLD UCLA Harbor (Involuntarily detained for a 72- hour psychiatric hospitalization due to threat of harm to self, others, or being gravely disabled)
Injuries
No Harm Contract
Parametrics or Fire Department
Other Agency Release Sign off

Recommendation – Reason for Referral State:Provide Immediate Stabilization at School Site :Early dismissal and pick up by parent/guardianConfidential:

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File Upload

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HCIS Staff SignatureIf no parent or guardian is able to pick up the student right away, an HCIS Counselor will be available to ensure the comfort of the student while awaiting parent or guardian release. If a communicable disease is suspected, the student will be isolated immediately from the rest of the students. However, the student will remain under the supervision of an adult designated by the Principal. Copyright 2014

Unusual Incident Injury Report Form

– Step 1 of 5

Incidents Reports Policy

To ensure that all unwanted incidents are fully reported and appropriate actions are taken to correct problems the following procedures will be followed regarding reporting of incidents.

Incidents Reports Procedure

Definition – an incident is any unwanted situation requiring special intervention by staff. Incidents for which reports must be filed include those in which an injury is sustained by a staff member or student whether the result is an accident or an altercation. Any incident that results in a student being suspended for the remainder of the day or several days shall be reported. All incidents of the elopement of students from the campus should be reported. Finally, all psychiatric emergencies including credible suicide threats should be reported.

The senior staff member observing the incident should fill out the incident report. If the incident was not observed directly, information should be obtained from other observers or participants.

Incident reports must be completed as soon as is practical after the incident and in most cases the same day as the incident occurred. In all cases, an incident report must be completed within 24 hours of the incident.

The incident report (as of this procedure) should be filled out completely and should be accurately dated, timed, and signed with the staff member’s title.

One copy of the incident report should be placed in the student’s medical report, one copy should be filed in the program’s incident report file and two copies should be sent to the main corporate office one to the director of said site.

Patient(s) Involved (include DOB/UCI):Mental Health Staff Involved:Party Involved:

Parent
Guardian
Caretaker
Other

Date/Time Occured:DateTimeName *FirstLastGender

Female
Male

AgeDate of AdmissionOnly if applicable pleaseAdd More

I need to add more people that were to Unusual Incident Report

Party Involved (2):

Parent
Guardian
Caretaker
Other

Date/Time Occured (party 2):DateTimeName (party 2) *FirstLastGender (party 2)

Female
Male

Age (party 2)Date of Admission (party 2)Only if applicable pleaseAdd More

I need to add more people that were to Unusual Incident Report

Party Involved (3):

Parent
Guardian
Caretaker
Other

Date/Time Occured (party 3):DateTimeName (party 3) *FirstLastGender (party 3)

Female
Male

Age (party 3)Date of Admission (party 3)Only if applicable pleaseType of Unusual Incidents-Injuries:

Describe event or incident (include Date, Time, Location, Perpetrator, Nature of Incident, Any Antecedents leading up to incident and how patient(s), recipient of information and/or mental health staff were affected, including any injuries):Previous Reportable Incidents/Injuries:Explain what immediate action was taken (include person(s) contacted):Explain intervention used:Medical Treatment Necessary?

If Yes, Indicate Nature of Treatment:Where was medical treatment administered?Administered By: *FirstLastFollow-up Treatment, If Any:Action to Re-integrate, If Any:Service Plan Adjustment, If Any:Report Submitted By *FirstLastYour Title/PositionDateReport Reviewed/Approved By *FirstLastTitle/PositionDateAgencies/Individuals Notified

Specify Name, contact number, date, and any other information please

Patient Health Questionnarie (PHQ-9)

Name *FirstLastDate of BirthVisit Date

Over the last 2 weeks, how often have you been bothered by any of the following problems?

Little interest or pleasure in doing things

0 – Not at all
1 – Several days
2 – More than half the days
3 – Nearly every day

Feeling down, depressed, or hopeless

0 – Not at all
1 – Several days
2 – More than half the days
3 – Nearly every day

Trouble falling or staying asleep, or sleeping too much

0 – Not at all
1 – Several days
2 – More than half the days
3 – Nearly every day

Feeling tired or having little energy

0 – Not at all
1 – Several days
2 – More than half the days
3 – Nearly every day

Poor appetite or overeating

0 – Not at all
1 – Several days
2 – More than half the days
3 – Nearly every day

Feeling bad about yourself — or that you are a failure or have let yourself or your family down

0 – Not at all
1 – Several days
2 – More than half the days
3 – Nearly every day

Trouble concentrating on things, such as reading the newspaper or watching television

0 – Not at all
1 – Several days
2 – More than half the days
3 – Nearly every day

Moving or speaking so slowly that other people could have noticed? Or the opposite — being so fidgety or restless that you have been moving around a lot more than usual

0 – Not at all
1 – Several days
2 – More than half the days
3 – Nearly every day

Thoughts that you would be better off dead or of hurting yourself in some way

0 – Not at all
1 – Several days
2 – More than half the days
3 – Nearly every day

FOR OFFICE CODING

Total Score of 1's+ Total Score of 2's+ Total Score of 3's= Total Overall ScoreIf you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?

Not difficult at all
Somewhat difficult
Very difficult
Extremely difficult

Referral Form

Referring To

Practice NameProvider Name *FirstLastIf requested physician is unavailable, can patient be sen by another provider?

AddressAddress Line 1Address Line 2CityStateZip CodePhone

Reason for Referral

List reason for referralPresenting problemLast lab resultsMedications

Patient Information

Patient Name *FirstLastDateAddressAddress Line 1Address Line 2CityStateZip CodePhonePrimary InsurancePolicy #Group #Guarantor Name *FirstLastGuarantor DOBDateTimeSecondary InsurancePolicy #Group #

Referring Provider

Name *FirstLastSignatureDate