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Critical Behavioral Health Incident Report (CBHIR)
The Critical Behavioral Health Incident Report is an internal report delivered to the J1 Special Programs Office having to do with any serious mental health concerns or self-injury including documenting any ASIST interventions.
John Dixon, LPC - Northeast Oklahoma
(918) 513-1992
Danielle Gonzalez, LMSW - Central Oklahoma
(405) 228-5323
Gwendolyn Johnson, LPC - Southwest Oklahoma
(405) 239-0418
Type of Incident:
High Stress Situation
Unusual Pattern of Behavior
Domestic or Intimate Partner Violence
Substance Abuse Situation
Suicidal Ideation
Suicide Attempt
Date and Time:
Location:
Subject / Victim Information
Name:
First
Last
Gender:
Male
Female
Other
Are you a member of a Native American tribe?
Yes
No
Unit and Station of Assignment:
Relationship Status:
Single
In a relationship
Engaged
Married
Widowed
Separated
Divorced
Have you deployed? If so, where and when:
Current Contact Information
Address:
Street
City
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District of Columbia
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Country
Zip
Home Phone:
Cell Phone:
Summary of Incident
Provide summary of incident with attention to: what happened, how did this incident come to your awarenss; outline general response; outcome - include where the person was taken for any treatment; any known precipitants to the event, etc.
Outcome:
Hospitalized
Provided ASIST Safeplan only
Evaluated but not hospitalized
If not hospitalized, provide elements of Safeplan established for this intervention:
Was law enforcement involved?
Yes
No
Personal Information
Is the service member a gun owner?
Yes
No
Unkown
Does the service member have a suicidal ideation with a plan?
Yes
No
Unknown
If yes, what was the plan?
Charged with any of the following crime or crimes? Please select all that apply.
Drug use/possession
Drug distribution
Abuse of spouse/significant other/child
Assault
DUI
Arrest
Other Crimes:
Command Information
Point of contact for this report:
POC phone:
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