Crisis Psychotherapy/Crisis Intervention Note

Date of Service: [Date]
Service Time: [Start–Stop time / Total minutes with patient] (Document patient-facing crisis time; note collateral-only time separately if applicable.)
Setting/Modality: [in-person / ED / urgent care / telehealth A/V / telehealth audio-only / mobile crisis / outpatient urgent slot / other: [Specify]]
Clinician: [Name, credentials]
Referral Source: [Referral source / self]
Reason for Urgent Encounter: [One-line summary of why crisis services are needed today]
Patient Location (telehealth only): [Address/city/state] (Include only for telehealth encounters.)
Callback Number (telehealth only): [Phone number] (Include only for telehealth encounters.)
Assessment Limitations: [Information that could not be obtained and why] (Include only if applicable.)

Chief Complaint & Crisis Presentation

Chief Complaint: [Patient's statement of presenting crisis] (Use patient's words when possible.)

Crisis Narrative: [Description of current crisis state, primary driver, precipitating events and timeline, current symptoms and severity, functional impairment, actions taken prior to arrival, and how today differs from baseline] (Primary crisis drivers include: suicidality / self-harm / homicidality / psychosis / severe panic/anxiety / intoxication/withdrawal / acute trauma reaction / mania / severe depression / other. Focus on details necessary for safety decisions and continuity of care.)

• Collateral Information: [Source name/relationship and key risk-relevant details] (Include only if materially affects risk or disposition.)
• Contributing Factors: [Substance use, medical issues, legal or social stressors, access issues] (Include only if relevant.)
• Assessment Barriers: [Intoxication, altered mental status, language barriers, non-cooperation] (Include only if present.)

Mental Status Exam

• Appearance: [Hygiene, attire, apparent age vs. stated]
• Behavior/Psychomotor: [Cooperation, psychomotor activity, notable movements]
• Speech: [Rate, volume, fluency]
• Mood: [Patient-reported mood]
• Affect: [Range, appropriateness, reactivity, congruence]
• Thought Process: [linear / goal-directed / circumstantial / tangential / disorganized]
• Thought Content: [SI/HI, delusions, hopelessness, obsessions] (Briefly qualify abnormal findings.)
• Perception: [Hallucinations present/absent; command content if present]
• Cognition: [Orientation, attention, memory as observed]
• Insight: [intact / limited / absent] (Include brief qualifier.)
• Judgment: [intact / impaired] (Include brief qualifier.)
• Impulsivity: [low / moderate / high] (Include examples if observed.)
• Intoxication/Withdrawal/Dissociation: [Signs noted] (Include only if relevant.)

Risk Assessment

• Suicide Risk
  • Ideation: [present / absent; frequency; intensity]
  • Plan: [Method, specificity, lethality, availability of means]
  • Intent: [present / absent; desire to die; preparatory behaviors]
  • Recent Behaviors: [Attempts, aborted attempts, rehearsals, NSSI with dates and medical severity]
  • Past Attempt History: [Number, methods, most severe, sequelae]
  • Lethal Means Access: [Firearms / medications / ligature means / other; secured/removed status and by whom]
  • Acute Risk Factors: [Current stressors, psychiatric symptoms, substance use, agitation, recent loss, isolation]
  • Protective Factors: [Internal strengths, reasons for living, social supports, treatment engagement]
  • Validated Screening Tool: [Tool name, score, interpretation] (Include only if administered.)
  • Overall Acute Risk Level: [low / moderate / high / imminent] (Include brief rationale tied to formulation.)
• Violence/Homicide Risk (Include only if clinically relevant.)
  • Ideation/Plan/Intent: [present / absent; specificity]
  • Identified Targets: [Names/roles if disclosed]
  • Access to Weapons: [Type, availability, storage]
  • Mitigation Steps: [Notifications, safety measures, coordination with authorities]
• Assessment Limitations: [Components not assessed, reasons, proxy information used] (Include only if applicable.)

Crisis Interventions & Response

• Stabilization Techniques: [De-escalation / grounding / distress tolerance / supportive containment / brief CBT or DBT strategies / motivational approaches] Response: [Observed clinical effect]
• Resource Mobilization: [Family activation, coordination with ED/mobile crisis, shelter/DV resources, transportation] Outcome: [Effect and next steps]
• Medication Interventions: [Medication, dose, route, time; rationale; response/adverse effects] (Include only if applicable.)
• Means Safety Counseling: [Steps discussed, responsible parties, timeline, status] (Include only if applicable.)
• Medical Necessity Statement: [Brief statement connecting interventions to presenting crisis state]

Assessment, Safety Plan & Disposition

Clinical Impression/Working Diagnoses: [Clinical formulation and diagnoses; why urgent crisis intervention was required today]

• Disposition: [discharge with supports / ED transfer / voluntary admission / involuntary hold / observation / other: [Specify]] Rationale: [Tied to risk formulation and capacity]
• Safety Plan:
  • Warning Signs: [Personal triggers and early signs]
  • Internal Coping Strategies: [Activities patient can do alone]
  • Social Supports: [People and places for distraction and help]
  • Professional Resources: [Clinic, after-hours line, 988, local crisis line, ED/911]
  • Means Safety Steps: [Specific actions, responsible parties, timeline]
  • Copy Provided: [yes / no; format]
• Follow-Up: [Scheduled appointments with dates/times, outreach plan, referrals, warm handoffs, care coordination tasks]
• Return Precautions: [Guidance on when/how to seek urgent or emergency care]
• Patient Agreement: [Agreement with plan / refusal; capacity determination; surrogate involvement if applicable]
• Involuntary Process: [Legal authority, clinical criteria met, key supporting facts, notifications] (Include only if applicable.)

Billing (Crisis Psychotherapy 90839/90840): [Total crisis psychotherapy time in minutes; attestation that service required clinician's full attention; add-on 90840 units if applicable] (Include only if billed as crisis psychotherapy.)