CRISIS PREVENTION AND INTERVENTION PLAN

CRISIS PREVENTION AND INTERVENTION PLAN
Date of Initial Crisis Plan:

MonthDayYear
Date
Date of Last Revision:

MonthDayYear
Date
Medicaid ID #:
Record #:
Name:

First NameLast Name
Date of Birth:

MonthDayYear
Date
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number:
Please enter a valid phone number.
Clinical Home/First Responder:
Emergency Phone Number:
Please enter a valid phone number.
Alternate Phone Number:
Please enter a valid phone number.
LME/MCO:
LME/MCO Phone Number:
County:
LIVING SITUATION
Living Situation:
If "Unstable" Describe:
In a crisis, assistance will be needed in the following areas (if not applicable, leave blank)
Children (if yes, indicate ages):
Pets (Yes/Blank):
Transportation (Yes/Blank):
Other (Describe the type of assistance needed):
Explain what help will be needed:
EMPLOYMENT (In a crisis, assistance will be needed to contact my employer)
Assistance will be needed (Yes/No):
Contact Name:
Contact Phone Number
Please enter a valid phone number.
Please inform them:
COMMUNICATION
Method:
Preferred Language:
If "Other", specify:
LEGALLY RESPONSIBLE PERSON
Guardian Appointed (Yes/No):
Legally Responsible Person Name:
Phone Number:
Please enter a valid phone number.
INSURANCE
Type of Insurance:
Name of Company or Payer (if Type is Private or Other):
Policy Number/Member ID:
DIAGNOSES
CURRENT MEDICATIONS
TRUE ALLERGIES (Medication(s) and reaction - Update/revise anytime there is a change)
POORLY TOLERATED MEDICATIONS (Medication(s) and reaction - Update/revise anytime there is a change)
MEDICAL/DENTAL CONCERNS

Name

First NameLast Name
Date of Birth:

MonthDayYear
Date
Medicaid ID #:
Record #:
SUPPORTS FOR THE INDIVIDUAL

List the individuals that should be called in the event of a crisis, indicate the calling order, provide contact information, and indicate if a consent to release information to that person exists.
CRISIS FOLLOW UP PLANNING

(Include contact number(s) if not provided above)
Who is the primary contact to coordinate care if the individual requires inpatient or other specialized care?
First Name Last Name Area Code Phone Number
Area Code Phone Number
Who will visit the individual while hospitalized? (This information should come from the individual and reflect the individual's preference)
First Name Last Name Area Code Phone Number
Area Code Phone Number
Who will lead a review/debriefing following a crisis? First Name Last Name
Within what timeframe? Timeframe
ADDITIONAL PLANNING DOCUMENTS

(Indicate if the individual has any of the following documents. If "Yes", attach the document to the Crisis Plan)
Individual Behavior Plan
Suicide Prevention and Intervention Plan
WRAP Plan
Futures Plan (youth in transition/young adult)
Advanced Directives
Living Will

Name

First NameLast Name
Date of Birth:

MonthDayYear
Date
Medicaid ID #:
Record #:
GENERAL CHARACTERISTICS/PREFERENCES
What I am like when I am feeling well. Describe what a good day looks like for me and provide examples of how I feel when I have a sense of overall wellness and wellbeing. Describe how I interact, appear, and behave.
Early signs that I am not doing well. Significant event(s) that may create increased stress and trigger the onset of a crisis. Examples include: anniversaries, holidays, noise, change in routine, inability to express medical problems or to get needs met, need medication(s), being isolated, etc. Describe what one may observe when I go into crisis. Include lessons learned from previous crisis events. Examples include: not keeping appointments, isolating myself, communicate loudly/hyper-verbal, etc.
Ways that others can help me...what I can do to help myself. Crisis prevention and early intervention strategies that have been effective. Describe prevention and intervention strategies that have been effective in keeping me out of crisis and/or restrictive facilities. Note any individuals to whom I respond best. Examples include: breathing exervices, journaling, taking a walk, etc.
Ways that others can help me...what I can do to help myself. Strategies for crisis response and stabilization. Focus first on natural and community supports. Begin with least restrictive steps. Include process for obtaining back-up in case of emergency and planning for use of respite, if an option. List everything you know that has worked to help me to become stable.
What has worked well with me...what has not worked well. Acceptable and unacceptable treatments that have and have not worked in past crises; Specific recommendations for interacting with the person during a crisis. Describe preferred and non-preferred treatment facilities, medications, etc. Describe how crisis staff should interact with me when entering a crisis. For example, I like music, I like to go for a walk, I like to be talked to, peer counseling, I don't like to be talked to, I don't like to be touched, etc.
Should be Empty:

CRISIS PREVENTION AND INTERVENTION PLAN

LIVING SITUATION

In a crisis, assistance will be needed in the following areas (if not applicable, leave blank)

EMPLOYMENT (In a crisis, assistance will be needed to contact my employer)

COMMUNICATION

LEGALLY RESPONSIBLE PERSON

INSURANCE

SUPPORTS FOR THE INDIVIDUAL

CRISIS FOLLOW UP PLANNING

ADDITIONAL PLANNING DOCUMENTS

GENERAL CHARACTERISTICS/PREFERENCES