Complete this report under any of the following situations:

• A client that sustains an injury during treatment;
• An unusual or unexpected incident occurs that jeopardizes the safety of a client;
• There is an allegation or reasonable suspicion of abuse of a client; OR
• As otherwise required by state licensing.

Questions regarding the Incident Report should be immediately directed to the Clinical Director and your site’s Office Manager.

INCIDENT REPORT FORM

This form will be added to the patient’s chart for tracking purposes.

Complete this form regarding any of the following situations PRIOR to discussing discharge with patient or patient’s family: 

• When preparing for graduation from treatment
• When limited progress over a significant duration in response to treatment has been observed
• When considering discharge from treatment due to other reasons (i.e., behavioral, home carryover, parental involvement, etc.)

Please discuss your recommendation briefly with your lead prior to completing this form. 

If needed, the plan may include a scheduled meeting with the clinical director and/or your lead to gain further understanding.

 Therapist Request for Designation of High Alert or Monitoring for High Alert Status.

The purpose of this form is for clinicians to provide input to the High Alert committee to propose a client be considered for the special designation of High Alert or to monitor a candidate for High Alert status. After you complete the form, the committee will review the information and provide you with an update, based on the High Alert criteria.

Please provide as much information as possible from the client’s therapy team.

High Alert considerations:

• Aggression to Self
• Aggression to Others
• Elopement
• Property Destruction