THIS CRISIS PLAN SHOULD ONLY BE FILLED OUT BY THE PRIMARY INDIVIDUAL THERAPIST

Fill out this form each time any of your emergency contact information changes.
If a suicide or self-injury crisis arises during group and you and your backup clinician cannot be reached your client may be terminated from our DBT skills training group.

My Name: Degree: License #: (primary therapist)
My Email Address:
My Office Phone:
My Other Phone: which is a
My Street Address:
My Fax Number:


Initials of my client:
I provide this client
Hours I will take calls from client:

During every DBT skills training group:
    I agree that I or my back-up therapist will be available via telephone to handle crises
    I am aware that my client could be terminated from the DBT skills group if I or my back-up therapist are unavailable during the DBT group time

I also agree to the following:
    I agree to schedule regular weekly individual therapy sessions with my client while participating in the DBT Skills Training Program.
    I agree to fill out this form any time my emergency contact information changes or if my client becomes markedly more suicidal.
    I agree to maintain overall clinical responsibility for my client and to be available on a 24-hour basis to independently assess for risk areas
            (not depending on the skills trainers to notify me or address such concerns) and manage the care of my client in a crisis.
    I agree to notify the DBT skills trainers when I will be on vacation or out of town.
    I agree to arrange for a back-up mental health professional trained in suicide assessment and intervention to be available to manage
            my client in a crisis when I am not available.
    I agree to notify the skills trainers and maintain transitional clinical coverage if my client decides to change primary therapists while in the
            DBT Skills Training Program at BRTC. If this is not possible, I will immediately notify Dr. Brown at BRTC.

If your client is at high suicide risk or in crisis requiring immediate intervention and you are unavailable, who should be called?

Your Back-up Therapist (when you are in town)
Name:
Office Phone:
Other Phone: which is a
Hours available for calls from client:

Your Back-up Therapist (when you are out-of-town)
Name:
Office Phone:
Other Phone: which is a
Hours available for calls from client:


Pharmacotherapist Name: Phone:
Case Manager Name: Phone:



Primary Axis I disorder (to report on bills and payment summaries)
Does your client meet DSM-IV criteria for Borderline Personality Disorder?
      If yes, how did you determine the diagnosis?
highest urge/ideation
in the last 30 daysmost recent act
Non-suicidal self-injury
Suicide attempt

Brief history of suicidal and self-injurious behaviors:


Describe the most recent and most severe suicide ideation and behavior in the last 2 months, including the dates, circumstances, and interventions (e.g. ER, medical ward, ICU).


If your client is ever assessed 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?


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.