"Functional Assessment/Crisis Plan: Chart Copy" - Oklahoma

Functional Assessment/Crisis Plan: Chart Copy is a legal document that was released by the Oklahoma Department of Mental Health and Substance Abuse Services - a government authority operating within Oklahoma.

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Download a printable version of the form by clicking the link below or browse more documents and templates provided by the Oklahoma Department of Mental Health and Substance Abuse Services.

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Download "Functional Assessment/Crisis Plan: Chart Copy" - Oklahoma

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Name of SOC Site
Date Developed:
Date(s) Reviewed/Updated:
Youth Name:
Team Members Present:
Functional Assessment/Crisis Plan: Chart Copy
* Each statement preceded with an * is a component of the functional assessment.
The
statements without the * are components of the crisis plan.
1. * Provide a clear description of the crisis behavior or situation:
2. * Frequency, intensity, duration of the behavior or situation:
3. * Triggers or setting events that lead to crisis behavior or situation:
4. * When does behavior not occur?
5. * How to identify that crisis may occur soon
(observation signs):
6. * What has been tried in the past, how was it implemented, did it work?
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Name of SOC Site
Date Developed:
Date(s) Reviewed/Updated:
Youth Name:
Team Members Present:
Functional Assessment/Crisis Plan: Chart Copy
* Each statement preceded with an * is a component of the functional assessment.
The
statements without the * are components of the crisis plan.
1. * Provide a clear description of the crisis behavior or situation:
2. * Frequency, intensity, duration of the behavior or situation:
3. * Triggers or setting events that lead to crisis behavior or situation:
4. * When does behavior not occur?
5. * How to identify that crisis may occur soon
(observation signs):
6. * What has been tried in the past, how was it implemented, did it work?
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7. *Benefits or function of the crisis situation or behavior?
(attention, gets what he/she wants, etc):
8. * Possible positive replacement behaviors:
9. * Things that could make the situation better or worse:
*What happens after the behavior?
10.
(what do they do, how do they feel, punishments, rewards, etc):
11. Steps or goals to prevent crisis in presence of triggers
(what, who, when, how often):
Remember to include formal and informal supports.
12. Steps to take during crisis situation
(what, who, when, how often):
Remember to include formal and informal supports.
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Signatures:
___________________________________
_________________
Parent/Guardian(s)
Date
___________________________________
_________________
Child/Youth
Date
___________________________________
_________________
Family Team Member
Date
___________________________________
_________________
Family Team Member
Date
___________________________________
_________________
Family Team Member
Date
___________________________________
_________________
Care Coordinator
Date
___________________________________
_________________
Family Support Provider
Date
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