Jail Diversion Non-Consumer Triage Form
South Central Crisis Service
On-Call Clinician
*
First Name
Last Name
Date:
*
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Month
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Day
Year
Date
Time Call Began:
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Hour
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Minutes
AM
PM
AM/PM Option
Demographic and Intervention Information
(Relationship to Client)
Caller Name:
*
First Name
Last Name
Police Department
*
Caller's Phone:
*
Client's Name:
*
First Name
Last Name
Client's Phone Number:
*
Age of Client:
*
If unknown, enter "00."
Client's Date of Birth:
*
-
Month
-
Day
Year
If unknown, enter "01-01-1000."
Client's Gender:
*
Male
Female
Other
Client's Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Clinician's Name:
*
First Name
Last Name
Agency:
*
Psychiatrist's Name:
*
First Name
Last Name
Reason for Call:
*
Disposition:
*
Was a follow-up appointment with the Peer scheduled?
*
Yes
No
If yes, what time is the appointment?
1
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12
:
Hour
00
01
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59
Minutes
AM
PM
AM/PM Option
Were there any problems with the case?
*
Yes
No
If yes, please explain problem with case:
Disclosures:
*
DCF
Family Member
None
Other
Name of Disclosure Party:
*
First Name
Last Name
Alert Sheet referenced (Only if present)?
*
Yes
No
Clinician Signature:
*
Time Call Ended:
*
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
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49
50
51
52
53
54
55
56
57
58
59
Minutes
AM
PM
AM/PM Option
Total Time of Call:
*
Total Minutes
Type of Call
*
Emergent
Routine
Urgent
Submit
Should be Empty: