Name
|
DOB
|
Date of Plan:
| Address | Health Card # | ||
| “ | Tel # |
| SDM/Next of Kin | Tel # | ||
| Relationship | After Hrs. # | ||
| Lead Agency | Tel # | ||
| Contact Person | After Hrs. # | ||
| Family Physician | Tel # | ||
| Psychiatrist | Tel # | ||
| Pharmacy Name | Pharmacy Tel# |
| Diagnosis | |
| Reason for the Plan:
|
| Precautions (including risks to self or others) :
|
| Plan:
|
| Allergies:
|
Special Diet: |
| Substance Abuse: Yes
☐
No
☐
Details: |
Community Treatment Order:
Yes ☐ No ☐ |
| Other Medical Concerns: | Probation Order:
Yes ☐ No ☐ |
CRISIS BEHAVIOUR PLAN
LEVEL ONE (Beginning escalation phase)
| Behaviours to indicate that a problem may surface | Response Recommended |
| |
LEVEL TWO (Pre-Crisis phase)
| Behaviours to indicate the continuation of problematic behaviour | Response Recommended |
| |
LEVEL THREE (Crisis phase)
| Behaviours require emergency services | Response Recommended |
| |
POST CRISIS PLAN
| Follow Up to Crisis/Debriefing/Feedback Plan: | |
| |
|
| Person Responsible for Feedback Loop: | |
I agree to have the information from this Crisis Plan shared with the following people/agencies:
Name of Person or Agency
|
Signature of Client or Substitute Decision Maker
|
Received copy of plan: √
|
Current Supporting Agency
:
(name)
|
||
St. Joseph Healthcare
|
||
COAST
|
||
Hamilton Police Services
|
||
Good Shepherd – Barrett Centre
|
||
Other:
(name)
|
||
Other:
(name)
|
I am in agreement with this Crisis Plan:
|
|
Client Signature:
|
Date:
|
Substitute Decision Maker Signature:
|
Date:
|
Witness Signature:
|
Date:
|
This plan is valid until: (date)
|
|
Person Responsible to Update Plan: (name)
|
** Please Note: Any changes to this document require updated copies to be sent to all the agencies signed for above