mental health incident report template is a mental health incident report template sample that gives infomration on mental health incident report template doc. When designing mental health incident report template, it is important to consider different mental health incident report template format such as mental health incident report template word, mental health incident report template excel. You may add related information such as .
mental health incident report template
9) reporting agency name, address & program element: full (unabbreviated) name, #### street name, state, zip code of agency and program element (s) the consumer is currently receiving (e.g., residential, supported housing, rist, partial care, outpatient, iotss, eiss, pact, icms, pes, ioc, supported employment, supported education, path, jis, post, short term residential sa treatment, long term residential sa treatment, halfway house, residential detox (non hospital & hospital), extended residential care, partial care sa treatment, outpatient sa treatment, intensive outpatient sa treatment, outpatient ambulatory detox (non hospital), opiate treatment program). 8) consumer’s residential service provider’s information: this is for mental health agencies only and information refers to residential services level of care: a+, a, b, or c agency name: full (unabbreviated) agency name agency site/address: #### street name, state, zip code agency program element: __________________ 9) is this consumer also served by the new jersey division of developmental disabilities (ddd)?
the consumer’s scheduled number of hours ## and scheduled number of days per week ##. (prior to the incident is important, not after the incident occurred) mm/dd/yyyy 14) has this consumer been discharged within the last 60 days from a stcf, ccis, state, county or private psychiatric hospital or another community mental health agency? this document was prepared by: first and last name title: ________________________ date: mm/dd/yyyy time: ##:## phone number: ###-###-#### e-mail address: _______________________ contact person if different than the preparer (include as many individuals as necessary to remain in the incident reporting loop) : first and last name title: _____________________________ phone number: ###-###-#### e-mail address: ____________________________ (note: e-mail address(es) listed here will be sent notification from dmhas.)
describe events leading up to incident, what happened, and any injuries to client or others. describe action taken by staff, any treatment given to client, and final incident reporting form get help dmh helpline office of consumer support crisis services mha screening tools civil commitment who we are. could have or had a negative impact on the mental and/or physical some agencies under-report incidents hcbs provider critical incident information form ,
mental health incident report template format
dhr office of licensing and monitoring incident reporting form. form revision date: 12/09/2009 mental health/substance use. alcohol use/posession. this form must be faxed to magellan behavioral health of pennsylvania, inc. within 24 hours of the incident occurrence. please fax to magellan quality how: handwritten or template forms; critical incidents / investigations; tracking ir : incident report; medication incidents; behavioral incidents; exploitation incidents abuse allegations against agency personnel providing mental health , ,