Sitemap

PERSONAL CHECKLIST: RATE ANY OF THE FOLLOWING THAT APPLY TO YOU

(RATE YOUR CONCERN: 1 = LITTLE CONCERN 2 = SOME CONCERN 3 = VERY CONCERNED)

Recognize your warning signs and use your coping skills to keep yourself safe and healthy.

Date

Triggers and Stressors

(Behaviors, situations and circumstances that put you at emotional risk)

Warning Signs

(Your behavior signals that show you’re growing more and more at risk)

My Coping Skills

What I can do to be calm and stay safe IN THE MOMENT

Things to do

My goals for healthy behavior

This has been verified by:

(Parent/Guardian or Support Person)

Date

Address of my physical location if different than on my safety protocol sheet:

Emergency contact person, if different that on safety protocol sheet:

Emergency support services, if different than on safety protocol sheet:

Columbia Suicide Severity Rating Screen

If yes to 2, ask questions 3, 4, 5, and 6. If No to 2, go directly to question 6

Date(Required)

Mental Health Diagnosis

Legal Guardian Information

Parent Information (if different than above)

Insurance Information (please include a copy of the insurance card)

Name of primary insurance(Required)

Policy Holder(Required)

DOB of Policy Holder(Required)

Contact # to Insurance(Required)

Emergency Contact (will be contacted in the event of physical/mental health emergency)

Relation to Patient(Required)

Patient Questionnaire

What symptoms or problems are you hoping to address?(Required)

If yes, who referred you?

If yes, what specific service have you been referred to?

Where have you been treated for this/these symptoms or problems (or other symptoms/problems) before?

Outpatient provider/program

Inpatient provider/program(Required)

If yes, prescriber:(Required)

List any medications and any side effects:(Required)

What did you find most helpful in your previous treatment?

What did you find least helpful in your previous treatment?

Telehealth Assessment

WBI clinic outpatient services are provided through telehealth video services which are secure and follow federal safety standards. While teletherapy is unique and designed to meet the needs of the patient and family and can be provided in the comfort of your own home, it is both the patient and the provider’s responsibility to ensure confidentiality. Providers will work with the patient and their family to support the comfort of teleservices, privacy for all patients, and ensure teleservices are provided appropriately. Patients who are unable/uncomfortable with receiving teleservices will be provided referrals to other programs, when available.

Telehealth Assessment Participants

Date of Assessment(Required)

If yes, explain:(Required)

Sitemap

Sitemap

Pages

Priority List

PERSONAL CHECKLIST: RATE ANY OF THE FOLLOWING THAT APPLY TO YOU

Crisis Safety Plan

Recognize your warning signs and use your coping skills to keep yourself safe and healthy.

Outpatient Daily Check In

Safety screening

Columbia Suicide Severity Rating Screen

If yes to 2, ask questions 3, 4, 5, and 6. If No to 2, go directly to question 6

Risk Formulation

Interventions

Outpatient Referral Packet

Patient Information

Legal Guardian Information

Parent Information (if different than above)

Insurance Information (please include a copy of the insurance card)

Emergency Contact (will be contacted in the event of physical/mental health emergency)

Patient Questionnaire

Inpatient Program

Medications

Telehealth Assessment

Telehealth Assessment Participants

Access Questions