Crisis Policy

While uncommon, crises do occur in the Community Counseling Clinic (CCC). CCC counselors should become very familiar with the clinic crisis policy before beginning to see clients:

• In case of homicidal or suicidal ideation, or other clinically serious situations, counselors must assess whether clients have definite thoughts to hurt themselves or others. Counselors are required to call the Clinic Director or group supervision instructor to conduct a suicide/homicide risk assessment.

• CCC counselors must review the clinic crisis policy at the start of counseling services. Should assessment become necessary, the counselor should reference the informed consent regarding the crisis policy and stress that the counselor is in training  and will need to contact additional support to ensure client quality of care and safety.

• CCC counselors must pass the CCC Operations Quiz and attend the professional development training on using the CSSRS, a risk assessment tool, provided through the clinic.

• CCC counselors should prioritize their own safety: if clients make a direct threat of harm or become physically violent, the counselor should make all reasonable efforts to exit the counseling room and seek support from their Practicum Instructor. Peer Supervisors observing sessions must communicate these incidents to Practicum Instructors immediately. 

  • CCC counselors can communicate the need to request additional time in the counseling room from the clinic team as a means to exit.

The following questions can help guide the initial assessment of risk:

• You indicated having thoughts of [ending your life; acting violently; hurting others]. Tell me more about these thoughts.

• How often are you having these thoughts of suicide (or harming others)? How long do they last? What are these thoughts telling you?

• Do you have a plan? Have you been planning to end your life (or harm others)? If so, how would you do it? Where would you do it?

• Do you have the means (e.g. drugs, gun, rope, etc.) that you would use? Where is it right now?

• The CSSRS protocol can be downloaded to your phone as a App and that gives you all the exact worded questions to ask your clients when assessing risk.  It is highly recommended that you download this protocol App after completing the CSSRS training.

STOP and contact your Practicum Instructor and/or Clinic Director after you have done this brief assessment and if there is any concern of risk. 

Once the Clinic Director or Practicum Instructor is contacted, they will knock on the CCC counselor's door (or enter the Zoom Meeting) and ask the counselor to step outside or provide some preliminary information. At this time, the counselor should briefly describe the situation and the initial risk assessment. The Practicum Instructor or Clinic Director will enter the room and conduct a crisis evaluation in collaboration with the counselor.

Crisis Documentation Policy:

• Should no further action be needed after the initial assessment questions, the CCC counselor must document the initial questions and the client's responses in their weekly clinical case note.

• Should further evaluation and assessment by the Practicum Instructor and/or Clinic Director be warranted, but the client is found to be at low risk, the CCC counselor and the evaluator should collaborate to complete a CCC Crisis Note in addition to their clinical case note.

• Should further evaluation and assessment by the Practicum and/or Clinic Director be warranted and the client be found to be at moderate to imminent risk, the evaluator will complete a Safety Plan with the client which needs to be signed (or acknowledged if done virtually) by client. The Safety Plan must be documented in writing, and a copy must be uploaded to the client's chart as well as given to the client, (screenshot from a screenshare - counselor confirm receipt with a client screenshare). The CCC counselor and evaluator must complete a CCC Crisis Note, separate from the counselor's clinical progress note.

  • Additionally, the CCC counselor and evaluator may contact Project Respond at (503) 988-4888 for additional assessment and possible emergency support or request a wellness check from the Multnomah Crisis Intervention Center, which oversees Project Respond .

  • The CCC counselor is responsible for the follow-up strategy determined on the Safety Plan in collaboration with their Practicum Instructor and/or Clinic Director.

• Should further evaluation and assessment by the Practicum Instructor and/or Clinic Director be warranted and the client be found to be at high risk, the evaluator will inform the client that they have been found to be at significant risk for harm to themselves by suicide or harm to others. At this time, the evaluator will determine appropriate steps which may include, but are not limited to:

  • Drafting a Safety Plan with client(s).

  • If client is willing to undergo voluntary hospitalization, contact the Clinic Director for further assistance in coordinating care with the Healthcare system of the client's choice, or the one that is covered by the client's health insurance carrier whenever possible. The Clinic Director will secure an authorization for the release of information, and ensuring client has checked-in for services.

  • If client is unwilling to travel for voluntary hospitalization, but is willing to be screened, contact Project Respond at (503) 988-4888 for additional screening and emergency support.

  • If the client is unwilling to travel for voluntary hospitalization or be screened, reinforce for the client that you are a mandated reporter and screening services or 911 will be contacted, regardless. Should client insist on refusing hospitalization or screening and/or terminate session, evaluator will contact 911 followed by Project Respond and provide the client's physical address.

  • Once client safety is reasonably assured, the CCC counselor and evaluator must complete a CCC Crisis Note separate from the counselor's clinical progress note (see Documenting the Crisis below).

Safety Planning | The Community Counseling Clinic provides Safety Plans to be completed by the Practicum Instructor and/or Clinic Director with counselor(s) and client(s). The Safety Plan provides strategies for maintaining client safety and explicitly states the follow-up plan and next steps should risk factors increase. 

• The Safety Plan must be fully completed, crafted with the client(s) present, and endorsed by the client(s). 

• A hardcopy of the Safety Plan must be filed in the client record with the Crisis Note. The original Safety Plan is given to the client at the conclusion of crisis intervention or their session with the counselor.

• Safety Plans do not guarantee client welfare or safety. Counselors must consult with their Practicum Instructor or Clinic Director when finalizing the Safety Plan and before terminating contact with clients.

Documenting the Crisis | Once client safety is reasonably assured, the CCC counselor and attending clinical supervisor are expected to complete the CCC Crisis Note. Crisis notes document all details relevant to a crisis incident and must not include data related to the counseling process or more appropriate for the Clinical Case Note. Crisis notes must follow the following minimum requirements: 

• Crisis notes must be completed with the oversight of the attending clinical supervisor who conducted the safety evaluation. Crisis Notes must be indicated as such in Titanium and should be completed as a separate note from the Clinical Case Note.

  • Crisis notes can only be signed by both the counselor and the attending Practicum Instructor or Clinic Director, not peer supervisors.

• Crisis notes must identify the client’s crisis, not a significant support person’s crisis. 

• Crisis notes must document the urgency and immediacy of the situation.

• If a Safety Plan is issued to the client, then a copy of the Safety Plan must be attached to the Crisis Note in the client record.

In addition to the above minimum requirements, all Crisis Notes must adhere to the provided documentation format, which includes the following information:

• Crisis

  • Relevant clinical details about or leading up to the crisis

  • How the crisis is related to a mental health condition 

  • How the client is imminently or currently a danger to self or to others or is gravely disabled 

  • If relevant, why the client either requires psychiatric inpatient hospitalization or psychiatric health facility services.

• Intervention

  • Interventions by the counselor and attending evaluator that decrease, eliminate, alleviate danger, reduce trauma, and/or ameliorate the crisis. 

• Plan

  • The aftercare safety plan.

  • Collateral and community contacts that will participate in follow-up.

Crisis Notes are provided their own template and note type in Titanium Schedule. Crisis notes must be completed immediately following the crisis incident, without exceptions.