Crisis Response Note (Student)

(Use neutral, behaviorally specific language. Use direct quotes for threats, suicidal/homicidal statements, intent/plan statements, refusals, and critical consent statements. Time-anchor key actions. If a core element cannot be completed, document "unable to obtain" with reason and compensatory steps.)

Date of Service: [Date]

Start/End Time: [HH:MM] - [HH:MM]

Location: [on-campus location / off-campus / remote]

Encounter Type: [crisis response / walk-in / referral / threat assessment interview / postvention follow-up]

Mode: [in-person / phone / video]

Student: [Name], [DOB], [grade/year], [school]

Author: [Name], [role]

Supervisor of Record: [Name], [credentials]

Participants Present: [student alone / list names and roles of others present]

Language/Interpreter: [Language; interpreter name/ID if used]

Consent Status: [student assent obtained / parent-guardian consent obtained / emergency exception invoked]

Reason for Contact & Precipitating Event

[Who initiated encounter and why; referral source]. [Precipitating event(s) raising safety concerns]. [Immediate antecedent: argument, disclosure, social media post, threat report, observed behavior]. [Student's stated concern]. [Specific trigger for crisis response: suicidal statement, self-harm evidence, threats, severe dysregulation]. (Attribute each piece of information to source. Use direct quotes for safety-critical statements.)

Relevant Background (Crisis-Relevant)

• [Prior suicidal behavior or self-harm history with approximate dates]
• [Prior threats or violence concerns with context]
• [Current mental health treatment and providers]
• [Known diagnoses if verified]
• [Current medications and adherence concerns]
• [Acute stressors: bullying, loss, legal issues, housing instability, family conflict]
• [Substance use concerns relevant to acuity]
• [Protective supports and trusted adults]
• [Relevant IEP/504 or existing safety plans]
• [Limitations of history gathering if applicable]

(Include only what is available and pertinent. If history unavailable, document reason.)

Current Presentation

• [Appearance and level of distress]
• [Cooperation and engagement]
• [Speech: rate, volume, coherence]
• [Mood/affect: self-reported and observed]
• [Thought process and safety-relevant thought content]
• [Orientation and attention]
• [Psychomotor changes]
• [Perceptual disturbances if suspected]
• [Intoxication indicators if suspected]
• [Safety-relevant behaviors: attempts to leave, statements of intent, inability to engage in safety planning]

Risk Assessment

(Explicitly document both presence AND absence of key indicators. Use direct quotes for ideation, threats, intent, plans. If student declines to answer, document refusal and alternate data sources used.)

Suicide/Self-Harm Risk

• Ideation: [present / absent / unable to obtain]; [frequency, intensity, current vs. recent; quoted content]
• Plan: [present / absent / unable to obtain]; [specificity, feasibility, timing, location]
• Intent: [present / absent / ambivalent / unable to obtain]; [desire to act, inhibiting factors; quoted statements]
• Behaviors: [preparatory actions / past attempts / recent self-harm / none reported]; [dates, severity]
• Access to Means: [medications / sharps / firearms / other / none known]; [storage and access details]
• Timeframe: [Timeframe for ideation/intent]
• Protective Factors: [Reasons for living, supports, future orientation, coping skills]
• Acute Modifiers: [intoxication / agitation / psychosis / severe insomnia / recent loss / none]
• Screening Tool: [Tool name, scores, interpretation; or none used]
• Collateral Information: [Source and content; note limitations]

Violence/Threat Indicators

(Include if threats toward others were reported.)

• Threat Content: [Quoted statement; identified target(s)]
• Plan/Means/Weapons Access: [Details or none known]
• Intent and Pathway Indicators: [Ideation, planning steps, rehearsal, approach behaviors]
• Threat Assessment Process: [initiated / not indicated / pending]; [team members, next steps]

Risk Formulation: [3-6 sentence synthesis stating acuity level (acute imminent / elevated but not imminent / no current indicators), specific supporting facts, uncertainties or limitations, and rationale for why chosen disposition is least restrictive safe option]. (Use "based on available information" language; avoid false certainty.)

Actions Taken

(Time-stamped entries. If an intervention was considered but not done, document why.)

• [HH:MM] [De-escalation or environmental safety action: moved to safe room, line-of-sight supervision, removed hazards]
• [HH:MM] [Clinical action: risk assessment completed, safety plan created/reviewed, coping strategies practiced]
• [HH:MM] [Lethal means counseling: means addressed, agreed steps]
• [HH:MM] [Supervision consult and/or crisis team activation]
• [HH:MM] [Other coordination: nurse evaluation, additional clinical consultation]
• [HH:MM] [Resources provided: crisis line information, safety plan copy]

Notifications & Contacts

Supervision:

• [HH:MM] [Method: in-person / phone / message]; [Supervisor name]; [Guidance provided and effect on disposition]

Parent/Guardian Contact:

• [HH:MM] [Number/method]; [Outcome: reached / voicemail left / no answer]; [Information communicated or reason unable to reach]; [Interpreter used if applicable]
• (Document all attempts, alternate contacts tried, and escalation steps per policy.)

School/Administrative Notifications:

• [HH:MM] [Role/name notified]; [Reason for notification]; [Minimum necessary content shared]

External Notifications:

• [HH:MM] [Agency: mobile crisis / EMS / ED / law enforcement / child protection]; [Person spoken with]; [Disposition recommendation]; [Case/reference number]

FERPA Health/Safety Emergency Exception: (If applicable.) [Articulable and significant threat]; [Parties to whom information was disclosed]; [Rationale]

Safety Plan

(If no safety plan was created, document why and what interim safety measures are in place.)

• Warning Signs: [Student-identified signs]
• Internal Coping Strategies: [Strategies doable without others]
• People/Places for Distraction: [Names, locations, contact info]
• Trusted Adults to Ask for Help: [Names, roles, contact info]
• Professional Resources: [School contacts; 988/crisis line; emergency options]
• Lethal Means Safety Steps: [Specific actions; who is responsible; timeframe]
• Plan Distribution: [Who received a copy and method of delivery]

Disposition

[HH:MM] [Final disposition: returned to class with supports / sent home with guardian / transported to ED / referred to mobile crisis / other]. [Condition at handoff: distress level, current ideation/intent status, supervision status]. [Who student left with; verification method if required]. [What was reviewed with receiving party: risk summary, safety plan, warning signs, next steps]. (If recommended level of care was declined, document recommendation made, risks explained, caregiver's stated reasoning in quotes, and alternative plan implemented with supervisor involvement.)

Follow-Up Plan

• Next Contact: [Who, when, where—date/time specific]
• School-Based Follow-Up: [Check-in schedule, re-entry meeting, counseling appointment]
• External Follow-Up: [Referrals made, appointment status, warm handoff status]
• Safety Monitoring: [Who monitors, escalation triggers, after-hours protocol]
• Resources Provided: [Materials, hotlines, community supports given to student/family]

(If follow-up cannot be scheduled, document barrier and contingency plan.)

Record Type & Confidentiality

This note is part of [an educational record (FERPA) / a healthcare record (HIPAA)]. Limits of confidentiality were reviewed with [student / student and guardian] during this encounter.

Signatures

Author Signature: [Name], [credentials/role], [date], [time]

Supervisor Co-Signature: [Name], [credentials], [date], [time] (Attestation of review and description of any direct involvement.)