Student Crisis Consultation Form
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3ST. JOHNS COUNTY SCHOOL DISTRICT
STUDENT SERVICES
STUDENT CRISIS CONSULTATION FORM
Date:
Referred By:
Student Initials/ID#
DOB:
Grade:
School:
Form Completed By:
Referred For: (Describe situation, i.e. written, verbal, action of concern)
1. Potentially Psychotic (check any that apply)
hand wringing
physically agitated
pacing
paranoid
delusional thoughts
poor or no eye contact
legs or hands shaking
obsessive or intrusive
hallucinations
thoughts
If student is unable or unwilling to comply with attempts at communication or you feel unsafe
proceeding, stop interview immediately and contact Administration/YRO.
2. Suicidal (check any that apply)
ideation
threats
self-injurious behavior
3. Homicidal (check any that apply)
ideation
threats
aggressive behavior
Interview Questions/Guide (place cursor in each expandable box to type response)
1.
Tell me more about why you were sent to see me.
2.
How long have you been feeling like this?
3.
Explore any thoughts of harming self or others
a. If they have not admitted to any, directly ask
Are you thinking of harming yourself or
others? Are you thinking about killing yourself or others?
b. Is there a plan on how this threat might be carried out? Ask for specific details how,
when, date, time, location. Any previous history?
c. What’s the student’s potential ability to carry out this threat? (Do they have access to
weapons? Do they have opportunity? Unsupervised time?)
4.
Has anyone close to you ever harmed themselves or someone else? ___Yes ___ No
a. If yes, tell me more about that (who, when, how, circumstances).
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