Student Crisis Consultation Form (Page 2 of 3) in pdf

Student Crisis Consultation Form Page 2

b. If yes, did you ever receive any counseling to help you process event? ___ Yes ___ No

Explore any other potential impacting factors (i.e. trigger event, any recent trauma student or

family has experienced, peer conflict, boyfriend/girlfriend issues).

Are you in any current mental health treatment? (therapy, medication management)

a. If yes, how often do you see provider? Who is it?

What kind of meds? Are you compliant with taking meds as prescribed?

b. Is there a history of Baker Act or in-patient treatment/hospitalization? ___ Yes ___ No

c. If yes, when, how many times, for what, where?

Can you name anything positive in your life right now?

a. Support people – family, friends, teacher, coach

b. Anything you are looking forward to? Future plans (weekend, next holiday, getting driver’s

license, school activity/dance)

c. Any goals you are working towards? (getting a job, school goals)

Any other relevant information staff may have regarding student or family history (i.e. DCF,

DJJ, ASSIST, etc.)

After completing interview, if you still have concerns that student is in imminent

danger of harming self or others, contact administration/SRO for Baker Act evaluation.

If you do not feel there is a concern for imminent danger, what follow up actions were taken?

Follow up appointment set for: (date)

(location)

Student back to class

Phone call with parent

Referred to administration

Referred to social worker

Referred to guidance

*This form must be faxed to District Mental Health Social Worker, Laura Barkett, no later than the end of the

same school day. Fax (904)547-7595

Student Crisis Consultation Form Page 2