Get Mobile Crisis Referral Form - Crisis Response Network

Filling out the Mobile Crisis Referral Form online is a crucial step in ensuring that individuals in crisis receive timely support. This guide will provide you with a clear, step-by-step approach to accurately complete the form and facilitate a smooth referral process.

Follow the steps to successfully complete the Mobile Crisis Referral Form.

1. Click the ‘Get Form’ button to obtain the Mobile Crisis Referral Form. This action will open the form in an appropriate editor, allowing you to begin filling it out.
2. In the first section of the form, provide the referring school name and contact number. Clearly state the present issues or reasons for the referral, and include the date and time of the call.
3. Indicate the name of the crisis dispatch person and circle the level of school concern, which can range from low to imminent. Remember to contact the Mobile Crisis Team if the concern is rated at level 5 or higher.
4. Complete the student information section. Enter the student’s name, ID number, date of birth, age, and gender, along with the parent or guardian’s name and phone number. Indicate if the parent or guardian has been contacted.
5. Fill in the student's mailing address, including street, city, and zip code, to ensure accurate correspondence.
6. Proceed to the school assessment section. Mark the general disposition of the student by selecting applicable issues such as anxiety attacks, changes in appetite, or other relevant behaviors.
7. List any medical conditions the student may have, as well as any medications currently being taken. Ensure to document any prior hospitalizations and previous involvement with the Department of Child Safety.
8. Assess and indicate any suicidal or homicidal ideation, including plans or intent, and document any relevant notes that may aid in crisis intervention.
9. Complete the Mobile Crisis Team checklist by noting the names of the team members involved and confirming that they have debriefed with the school staff, provided safety plans, and received parent permission for transport if necessary.
10. Finalize your form by ensuring all sections are completed. Make sure to save your changes, and if needed, print or download copies for distribution to the Mobile Crisis Team and the school.

Ensure you complete and submit your Mobile Crisis Referral Form online to facilitate essential support for individuals in crisis.