Source: 2p. SIEC No: 20010074

This assessment & referral sheet is meant to be used with youth under age 25. Information is collected on demographics, assessment of immediate risk, current & previous deliberate self-harm, reasons for current crisis, signs & symptoms of current mental state & subsance use, the presence of supportive family, friends or caregivers, & other agencies involved in care. A copy of a green card used to remind the young person of a follow-up appointment is attached.