"Crisis Plan/Functional Assessment With Safety Plan Components" - Oklahoma

Crisis Plan/Functional Assessment With Safety Plan Components 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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Name of SOC/OHTI Site
Date Developed:
Date(s) Reviewed/Updated:
Young Adult’s Name:
Team Members Present:
Crisis Plan / Functional Assessment with Safety Plan Components
* 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/OHTI Site
Date Developed:
Date(s) Reviewed/Updated:
Young Adult’s Name:
Team Members Present:
Crisis Plan / Functional Assessment with Safety Plan Components
* 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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Safety Plan Components
13. Define appropriate behaviors
:
14. Define inappropriate behaviors
:
15. Plan for the 24-hour day
:
Discussion Points (if applicable)-
16. Proactive plan to educate children (ie: younger siblings) about safety issues:
17. Community safety-what are we doing to ensure the community stays safe:
18. Proactive plans for negative community reactions:
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Signatures:
___________________________________
_________________
Parent/Guardian(s)
Date
___________________________________
_________________
Young Adult
Date
___________________________________
_________________
Transition Team Member
Date
___________________________________
_________________
Transition Team Member
Date
___________________________________
_________________
Transition Team Member
Date
___________________________________
_________________
Care Coordinator/Transitional Facilitator
Date
___________________________________
_________________
Family Support Provider/Transitional Mentor
Date
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