Crisis Psychotherapy/Intervention Note

Date of Service: [Date of Service]

Start Time: [Start Time]   End Time: [End Time]

Setting/Location: [Setting/Location]

Modality: [in-person / video / phone]

Clinician: [Clinician name, credentials, role]

Participants: [Patient and all others present (family, collaterals, interpreter, crisis team, etc.)]

Source(s) of History: [Patient report]; [Collateral sources with names/roles] (Clearly distinguish patient report from collateral information.)

Chief Concern

[Patient-stated reason for contact and what makes this a crisis today] (1–3 sentences. Include a brief direct quote if it conveys acuity or intent. Identify the acute precipitant: loss of control, imminent safety concern, severe decompensation, or inability to maintain safety or function.)

Crisis Narrative

[Chronological account of events leading to crisis] (Include: trigger/precipitant and timing, escalation pattern, what prompted help-seeking now, current stressors (interpersonal, legal, occupational, housing, medical, substance-related, trauma reminders), and recent changes affecting acuity (medication changes, intoxication, insomnia, recent discharge, new access to means). Include relevant prior crisis history only if it directly informs current risk or disposition.)

(If intoxication, psychosis, or agitation limits ability to obtain coherent history, document barriers, collateral sources contacted, and plan for reassessment with timeframe.)

Safety Assessment

(Document both immediate screening and, when indicated, comprehensive risk assessment. For any item not obtainable, document "Unable to assess—[reason]" and the mitigation response. Never record negatives unless explicitly assessed.)

Immediate Safety Screen

• Suicidal ideation: [yes / no / assessed—patient declined / unable to assess—reason] — [timeframe]
• Self-harm or NSSI urges/behavior: [yes / no / assessed—patient declined / unable to assess—reason] — [timeframe]
• Homicidal ideation or violent intent: [yes / no / assessed—patient declined / unable to assess—reason] — [target if any]
• Grave disability/severe impairment in self-care: [present / absent / assessed—patient declined / unable to assess—reason] — [brief description if present]
• Acute intoxication or withdrawal risk: [present / absent / assessed—patient declined / unable to assess—reason] — [substance(s) if present]

(If any screen item is positive, unclear, or high-concern, complete applicable detailed sections below.)

Suicide Risk Details

(Include only if suicide risk screen is positive, unclear, or high-concern.)

• Ideation: [frequency, intensity, duration; last 48 hours and past month]
• Plan: [method, timing, location, lethality, preparatory acts]
• Intent: [expectation to act, ambivalence, reasons for living vs. dying]
• Behavior history: [past attempts, aborted attempts, rehearsals; recency; medical severity]
• Protective engagement: [willingness to accept help, willingness to follow safety plan]

Violence/Homicide Risk Details

(Include only if violence/homicide risk screen is positive, unclear, or high-concern.)

• Target and plan: [identified target(s), plan specifics, means]
• Intent and imminence: [intent to act, timeframe, opportunity]
• Past violence: [history, context, legal involvement]
• Psychotic factors: [command hallucinations, acute paranoia]
• Substance factors: [intoxication, withdrawal, substance use pattern]
• Access to weapons: [type, location, who controls access]

Risk and Protective Factors

• Risk factors: [prior attempts or violence, substance use, acute stressors, severe mood symptoms, psychosis, agitation, isolation, recent discharge, trauma exposure, medical comorbidity, access to lethal means]
• Protective factors: [connectedness, responsibilities to others, cultural/religious beliefs, coping skills, engagement in care, reasons for living, restricted means access, future orientation]

Means Access and Safety

(Include whenever self-harm risk is anything other than clearly absent.)

• Firearms: [access, location, storage status, who controls access]
• Medications: [stockpiles, high-risk medications, dispensing plan]
• Other means: [ligatures, sharps, heights, toxins as applicable]
• Actions taken this encounter: [removal, locked storage, third-party transfer, limiting quantities, supervision plan; who will do this and by when]

Risk Level Determination

Overall Risk Level: [Low / Moderate / High / Imminent / Unable to determine]

[Risk level rationale] (3–6 sentences addressing ideation, plan, intent, means access, dynamic vs. static factors, protective factors, and why the disposition is the least restrictive option consistent with safety. If "Unable to determine," specify reasons and mitigation plan including enhanced monitoring, collateral contacts, reassessment timeframe, and escalation thresholds.)

Mental Status Examination

(Document observed findings; distinguish observed vs. patient-reported. Cross-reference SI/HI to Safety Assessment rather than duplicating.)

• Appearance: [grooming, dress, hygiene, apparent age]
• Behavior/Psychomotor: [activity level, eye contact, cooperation, agitation, retardation]
• Speech: [rate, rhythm, volume, tone]
• Mood: [patient-reported mood in quotes]
• Affect: [observed range, intensity, congruence, lability]
• Thought Process: [organization, goal-directedness, associations]
• Thought Content: [delusions, obsessions, ruminations; SI/HI—see Safety Assessment]
• Perceptions: [hallucinations, illusions]
• Cognition: [orientation, attention, memory]
• Insight: [awareness of illness and need for treatment]
• Judgment: [decision-making capacity]
• Impulse Control: [observed impulse regulation]
• Intoxication signs: [intoxication or withdrawal indicators] (Include if relevant.)

Crisis Interventions & Response

(Time-ordered documentation of actions taken and patient responses. Be specific about techniques; avoid vague terms like "supportive therapy provided.")

• [Time] — [De-escalation or stabilization technique] — [Patient response]
• [Time] — [Resource mobilization (family, staff, crisis team)] — [Outcome]
• [Time] — [Risk mitigation step (environmental safety, observation level)] — [Outcome]
• [Time] — [Medication if provided: medication, dose, route, indication, consent obtained or refused] — [Response]

[Clinical course summary] (Brief narrative: change in agitation or distress, change in SI/HI intensity or intent, ability to collaborate on safety planning, remaining concerns at end of encounter.)

Safety Plan

(Include whenever any suicide risk is present or when discharging from urgent/emergent setting.)

1. Warning signs: [Patient-specific indicators that crisis may be developing]
2. Internal coping strategies: [What patient will do alone]
3. Social contacts and distractions: [People, places, activities]
4. Support persons to ask for help: [Names and phone numbers]
5. Professional resources: [Clinic contact, crisis line numbers, local crisis services, ED]
6. Means safety steps: [What will be locked or removed, who will do it, by when]
7. Caregiver/guardian role: [Supervision responsibilities and means safety tasks] (If applicable.)

Safety plan provided: [paper / portal / both / declined]   Patient demonstrated understanding: [yes / no / refused]

(If patient refused safety planning, document alternative mitigation: higher level of care, emergency activation, collateral involvement.)

Coordination & Handoffs

(Include when any coordination, consultation, or care transfer occurred.)

• Collateral contacts: [Who (name/role), when, information exchanged, outcome]
• Consultations: [Service/discipline, key recommendations, outcome]
• Warm handoff: [Receiving clinician/agency, acceptance confirmed, information communicated (risk level, means concerns, safety plan), transport plan]
• Consent/ROI: [obtained / not obtained—reason] (If disclosure under imminent-risk exception: document risk basis, who contacted, what shared.)

Disposition & Follow-up

Disposition: [remain outpatient with safety plan / urgent same-day evaluation / emergency department transfer / voluntary psychiatric evaluation / involuntary evaluation / admission / crisis stabilization unit / mobile crisis follow-up / other]

Justification: [Link disposition to risk level, means access, response to interventions, available supports, and ability to adhere to plan]

Follow-up: [same day / within 24 hours / within 72 hours] — [Appointment date, time, location if scheduled; or documented scheduling attempt]

Return precautions: [Symptoms or events that should trigger calling crisis line, presenting to ED, or calling emergency services]

Patient agreement: [agrees / partially agrees / disagrees] — [Response to disagreement if applicable]

(If discharging despite ongoing risk, document: why plan is adequately safe given protective factors and mitigation steps, why higher level of care was not pursued, patient refusal if applicable and your response.)

Diagnostic Impression

• [Primary diagnosis] — [provisional / confirmed] — [brief rationale]
• [Additional diagnoses as applicable]
• Key differentials affecting disposition: [Differential considerations]
• Psychosocial stressors: [Z-codes or descriptors]
• Functional impact: [Impact on safety, self-care, work/school, relationships]

Billing Documentation

(Include only when billing time-based crisis psychotherapy codes 90839/90840. Otherwise omit this section.)

• Service type: Crisis psychotherapy/intervention
• Total face-to-face time: [Total minutes] minutes
• Start and stop times: [Start time] – [End time]
• Time attestation: Documented time reflects direct crisis intervention activities (assessment, stabilization psychotherapy, safety planning, resource mobilization) and excludes non-clinical time.