1. Date of Plan:
    1. CRISIS BEHAVIOUR PLAN
    2. LEVEL ONE (Beginning escalation phase)
    3. CRISIS BEHAVIOUR PLAN
    4. LEVEL TWO (Pre-Crisis phase)
    5. LEVEL THREE (Crisis phase)
    6. POST CRISIS PLAN
    7. CRISIS PLAN
    8. CONSENT FORM

                          CRISIS PLAN

Hamilton Community Crisis Protocol
 

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#  

More personal information available on pg. 2

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
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 

 

 


 



CRISIS BEHAVIOUR PLAN


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:  



CRISIS PLAN



CONSENT FORM

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

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** Bring current Medication Administration Record (MAR) to Hospital/Crisis Service