CCBHC - Crisis Follow-Up

Referral for Crisis Follow-Up at Bridges
Mobile Crisis Clinician's name

First NameLast Name
Date

MonthDayYear
Date
Mobile Crisis Clinician's Email
example@example.com
Mobile Crisis Clinician's phone Number

Area CodePhone Number
Client Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Age
Gender
Grade
School
Special Education
Parent/Guardian Name

First NameLast Name
Parent/Guardian Phone Number

Area CodePhone Number
Reason for mobile crisis evaluation:
History of suicide attempts
History of psychiatric hospitalizations
Is client in psychiatric treatment
If yes, Name of current provider

First NameLast Name
Phone Number of current provider

Area CodePhone Number
List Current Psychiatric Medications:
DCF involvement
Phone Number of DCF Worker

Area CodePhone Number
Clinical impressions and recommendations:
If client is currently not engaged in services, would he/she like to have an intake at Bridges Healthcare, Inc. on the next business day?
Should be Empty:

Referral for Crisis Follow-Up at Bridges