Crisis Evaluation Note (Child/Adolescent)

Date/Time: [Date and time of evaluation]

Patient: [Patient name]

Age: [Age in years]

Setting: [clinic / ED / inpatient consult]

Participants Present: [Patient, parent/guardian with relationship, interpreter if used]

Referral Source: [self/family / school / PCP / therapist / crisis line / law enforcement / ED transfer]

Legal Guardian/Custody: [Guardian name(s) and custody status]

Consent: [Consent status and from whom obtained] (Note if youth interviewed alone for any portion.)

(Throughout this note: label information sources such as patient report, caregiver report, collateral contacts, prior records, and clinician observation. Anchor key events to times when available. For any safety-critical element not assessed, document the reason. Use brief direct quotes only for pivotal safety-relevant statements. Do not state absence of risk factors unless explicitly asked and answered.)

Chief Concern

[Presenting crisis summary] (Use patient and/or caregiver words when helpful; one to two lines.)

Immediate Safety Status

(Brief, factual snapshot of current risk before full narrative.)

• Current suicide/self-harm concern: [none / passive ideation / active ideation / plan / intent / recent attempt]
• Current aggression/violence concern: [none / verbal threats / physical aggression / weapon-related]
• Supervision right now: [responsible adult present / patient alone / other]
• Immediate safety actions taken: [belongings searched / sharps removed / continuous observation / security involvement / none required]

History of Presenting Crisis

[Narrative of precipitating event, context, and timeline] (Describe what happened, where, with whom, and why now. Include onset, escalation, duration, and when last at baseline. Integrate target symptoms/behaviors such as suicidality, self-harm methods, aggression, psychotic symptoms, panic, intoxication. Note functional impact. Label sources throughout.)

[Interventions attempted before arrival and response]

[Current stressors and any protective turning points]

[Collateral information summary] (List contacts by role; summarize key points and discrepancies with patient report. If no collateral obtained, state why and note implications for risk uncertainty.)

Relevant Background

• Prior suicide attempts: [Method, approximate date, lethality, rescue circumstances] (Include interrupted/aborted attempts.)
• Nonsuicidal self-injury: [Methods, frequency, function, last occurrence]
• Aggression/violence history: [Severity, pattern, weapon involvement, consequences]
• Psychiatric history: [Diagnoses, treatment levels, engagement and response]
• Current medications: [Names, doses, recent changes, adherence, who controls access]
• Substance use: [Current/past use, last use, intoxication/withdrawal concerns today]
• Family psychiatric and suicide history: [Relevant conditions in first/second-degree relatives]
• Trauma/adversity and home safety: [Notable history, current home safety, supervision adequacy, abuse/neglect concerns]

Suicide and Self-Harm Risk Assessment

(Include when suicidality, self-harm, or unclear safety is present. Omit if safety is clearly not a concern.)

Screening method: [Tool name and result / Clinical interview without formal tool]

• Ideation: [Passive vs active; frequency; intensity; duration; last occurrence]
• Plan: [Method considered; specificity; feasibility; timing]
• Intent: [Desire to die; perceived capability; reasons for living vs reasons for dying]
• Behaviors: [Preparatory acts; rehearsals; aborted/interrupted attempts; recent self-harm with method, severity, stated intent]
• Means access: [Firearms—presence, loaded/locked, ammo storage; medications—quantities, control; sharps; ligatures; heights; vehicle access]
• Protective factors: [Internal: reasons for living, future orientation, coping skills] [External: family support, therapeutic relationships, supervision]
• Aggravating factors: [Intoxication; agitation; psychosis/command hallucinations; severe insomnia; recent loss; impulsivity]
• Ability to collaborate: [Willingness to accept help; ability to participate in safety planning; caregiver capacity]

Risk formulation: [Chronic baseline risk factors] vs [Current acute risk elevation] (Explicitly distinguish baseline from current state.)

Overall suicide/self-harm risk level: [imminent / high / moderate / low] (Provide concise clinical rationale.)

Violence and Aggression Risk Assessment

(Include when aggression, threats to others, or severe dysregulation with impulsivity are concerns. Omit entirely if not applicable.)

• Current violent ideation/intent: [Targets, circumstances, specificity]
• Threats made: [Verbal / written / online; content; timing]
• Weapon access/carrying: [Types, access pattern, recent carrying behaviors]
• History of violence: [Most severe incident, pattern, consequences]
• Triggers: [Identified precipitants and situational factors]
• De-escalation responsiveness today: [Strategies used and effectiveness]
• Risk management needs: [Supervision level; separation needs; school safety considerations]

Violence risk level (next 24–72 hours): [high / moderate / low] (State factors that would increase or decrease risk.)

Mental Status Examination

• Appearance/behavior: [Grooming, eye contact, cooperation]
• Psychomotor activity: [Normal / increased / decreased / agitated]
• Speech: [Rate, volume, prosody]
• Mood: [Patient-stated mood]
• Affect: [Range, intensity, congruence, reactivity]
• Thought process: [Logical / linear / circumstantial / disorganized]
• Thought content: [SI/HI status; delusions; obsessions]
• Perceptions: [Hallucinations; command content if present]
• Cognition/attention: [Orientation, attention, memory as observed]
• Insight: [Understanding of condition and risks]
• Judgment: [Decision-making in safety contexts]
• Impulse control: [Adequate / limited / poor]
• Engagement and reliability: [Open / guarded / minimizing / intoxicated]

Assessment and Disposition

Diagnostic impression:

• [Acute safety problem with risk level]
• [Underlying contributing conditions]

Formulation: [Brief synthesis linking precipitating events, vulnerabilities, protective factors, and current safety picture]

Disposition: [inpatient psychiatric admission / ED transfer for medical clearance / mobile crisis / PHP/IOP referral / discharge with urgent outpatient follow-up]

Rationale: [Why this level of care is appropriate] (For discharge: why imminent risk is not present and why home/community is sufficiently safe. For admission: why lower levels are insufficient. Note voluntary vs involuntary pathway if applicable.)

Transfer/admission details: [Accepting facility; transport method; handoff completed with key risks communicated] (Include only if transferring or admitting.)

Lethal Means Safety

• Access identified: [Firearms; medications; sharps; ligatures; chemicals; heights; vehicle keys—findings for each assessed]
• Mitigation plan: [Specific actions agreed upon; responsible adult; how/where items stored; timeline] (If family cannot or will not complete actions, document barriers and how this influenced disposition.)

Safety Plan

(Required when discharging; recommended when admitting. Do not use safety contracts. If patient refuses, document refusal, components addressed, and effect on disposition.)

• 1) Warning signs: [Patient-specific internal and external cues]
• 2) Internal coping strategies: [Strategies patient can use independently]
• 3) People/places for distraction: [Names and locations]
• 4) People to contact for help: [Names and phone numbers]
• 5) Professional resources: [Outpatient clinician contact; local crisis line; 988; when to call 911 or go to ED]
• 6) Caregiver supervision plan: [Monitoring level; medication administration; check-in frequency]
• 7) Contingency plan: [Steps if coping fails or caregiver unavailable]

Follow-Up Plan

• Follow-up contact (24–48 hours): [By whom; method; scheduled date/time]
• Scheduled appointments: [Clinician name; date/time; location]
• Referrals and bridge plan: [Programs/services; expected wait; interim supports]
• School plan: [Return timing; counselor notified; consent status] (Include if relevant.)
• Escalation instructions given to: [Who received instructions; symptoms requiring ED/911]

Notifications and Confidentiality

(Include when applicable; omit if none apply.)

• Limits of confidentiality reviewed with patient: [Yes / No]
• Parent/guardian informed of suicidal risk and safety plan: [Yes / No; details]
• Mandatory reports/duty to warn: [CPS report filed / law enforcement notified / not applicable]
• Releases signed: [For coordination with school/outpatient providers; scope]

Author: [Name, credentials]

Date/Time Signed: [Date and time]

Supervision: [Supervising clinician name, credentials, and attestation] (Include only if applicable.)