Day __________ Date __________ Time ______ @ Length of Contact ________

Name ______________________________________

Social Security # ________________

Address ______________________________________ Phone # _______________

Location __________________ (Circle) Single Residential Life Housing    Village/Family Housing

Intervention/Contact Initiated by: (Circle)

Self Student Mental Health (SMS) Univ. Police Dept. (UPD) Univ. Counseling Center (UCC)

Dean of Students Office (DOS) University Athletic Association (UAA) Student Health Services

Division of Housing Staff Academic Advisement Other_________________________________

Nature of Problem(s): (Circle all appropriate)

Academic Problems Acute Psychotic Reaction Anxiety Assault/Battery Child Neglect/Abuse

Depression Relationship/Domestic Violence Relationship Problems Alcohol/Drug Abuse/OD

Sexual Assault Suicide Attempt Suicidal Thoughts Death/Sudden Loss Medical Emergency

Other _____________________________________________

Assessed Risk of Harm to: (Circle) Self Other(s)

None Low Medium High Not Assessed

Response to Recommended Transport Referral is: (Circle) Voluntary Involuntary

Others Involved in Intervention: (Circle All Appropriate) UPD Alachua Cty Crisis Center EMT

Fire/Rescue Victim Advocate Crisis Stabilization Unit Dean of Students Office Division of

Housing Staff Housing Security Shands Hospital Administrative Affairs Student Health Services

Physician/Staff Academic Advisement Univ. Counseling Ctr. Student Mental Health Services

University Athletic Association Other ________________________________________

Description of Intervention/Contact: In the space below provide a brief description of the incident, principal parties involved, and recommendation(s) - Use additional paper, if necessary.

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Recommendation(s) for follow-up or referral to: (Circle All Appropriate)

No further follow-up required EMT Crisis Center Fire/Rescue Student Mental Health Services

Univ. Counseling Center Crisis Stabilization Unit Academic Advisement Dean of Students

Division of Housing Administrative Affairs UPD Victim Advocate Shands Hospital

Student Health Services University Athletic Association Other Psychiatric /Medical facility

Other _____________________________________________________________________

______________________________________________________ ____________

Name and Title of Person providing information                             Date of report