Crisis Plan for DBT Skills Group
This crisis plan should only be filled out by the primary individual therapist. This form must be filled out via the web form. Handwritten copies will not be accepted.
Who is filling out this form?
Name of Primary Therapist
Name of patient who wants to enter DBT group
How often do you usually meet with the client face-to-face?
At least once per week
2-3 times per month
less than twice per month
What types of psychotherapy interventions do you provide in most meetings?
When (days of the week and times of day) will you take crisis calls from this patient?
Do you have a back-up therapist who we should call if our patient calls us, and we determine he/she is at risk for suicide? Give details.
Who is the psychiatrist or pharmacotherapist? Give details and contact information. Type in "None" if applicable.
Who is the case manager? Type in "None" if applicable.
For which DSM disorders that you have thoroughly assessed does the patient meet full criteria?
Which DSM disorders have you thoroughly assessed and ruled out?
Which DSM disorders are probable, but not yet fully determined?
When was the most recent time the patient injured him/herself but had no intention to die? What exactly did he/she do?
Has the patient ever thought about or attempted to kill him/herself?
It was just a passing thought
Briefly considered it - but not seriously
Thought about it and was somewhat serious
Had a plan for killing myself which I thought would work and seriously considered it
Attempted to kill self - but with ambivalent intent
Attempted to kill self and strongly hoped to die
When was the most recent time the patient attempted suicide? If the patient has never attempted suicide then instead describe the most recent episode of intense suicide ideation, planning, or threats. Include the date, the specific behavior or plan, circumstances, and interventions (e.g. ER, medical ward, ICU). Give details.
When was the most recent time the patient had a plan for killing herself which she/he though would work and seriously considered it? Give details.
Describe the most severe suicidality in the lifetime. If the patient has never attempted suicide then instead describe the most severe episode of suicide ideation, threats, or planning. Include the date, the specific behavior or plan, circumstances, and interventions (e.g. ER, medical ward, ICU)
Describe all the previous suicidal behaviors, methods, and plans that were not described in detail above. Enter N/A if your client has never attempted or planned suicide.
Are any of the suicide methods previously used or planned available to the patient or easily obtained? If so, please explain. Enter N/A if your client has never attempted or planned suicide.
Describe any history of violence and use of weapons. Also specifically describe any occasions of violence and use of weapons in the last 2 months.Describe any current plans that you and the client have to deal with this behavior.
If we ever assess your patient as being in imminent risk of suicidal behavior or self-injury and neither you nor your backup can be immediately contacted, how should our team manage your client? Under what circumstances should we refer the client to the Crisis Line, call the police, or take the client to an emergency room?
Has any family member or friend of the patient committed suicide?
I never asked
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