Crisis Care Reporting Form

Team member who took the call
Name of the caller.
Other people involved?
Street Address
City
Phone number
Date and Time of call
What type of situation is this?
  • Immediate (visit w/in 1 hr)
  • Urgent (visit w/in 48 hrs)
  • Phone Call Only
Describe the crisis situation
Crisis team members who made the visit.
Date & Time of the visit
Describe the visit.
Are there any referrals to be made?
Have you called the team leader, Jane Kraft at 627-5444 or 628-4900 x203 (office) to debrief your visit?
  • Yes
  • No
Are there resources or supplies that need to be replenished in the resource kit? Please list
  • Yes
  • No