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CRISIS REPORT
HUB #SOS
Crisis Report
Person you spoke with?
Your Name
Email Id Of Person You Spoke With
Date
Time
The Client Has Displayed / Discussed / Disclosed One Or More Of The Following
Verbally saying they want to harm themselves
Talking about feeling empty
Mentioning strong feelings of guilt and shame
Talking about not having a reason to live or that others would be better off without them
Social withdrawal and isolation
Talking about giving away personal items and wrapping up loose ends
Saying goodbye to friends and family
Verbally discussing having access to lethal means and a plan to end their life
Past suicide attempts
A family history of suicide
Being exposed to another person’s suicide
Dealing with suicidal thoughts and feelings
Notes: Please provide a detailed report of (#1) Observed behaviour and actions during the session (#2) Any statements made that indicate risk (including the above and verbatim if possible) (#3) Total duration of the session and (#4) Any professional guidance given.
I agree to the terms of counselling and have abided by the norms set by the company.
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Thanks. Please direct the person to other helplines.
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