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.

Amber McCoy

OKARNG Alcohol and Drug Control Officer

(405) 228-5343

Michele Burris, MEd, LPC

OKARNG Behavioral Health Coordinator

(405) 228-5325

Type of Incident:

Date and Time:

Location:

Name:

First

Last

Gender:

Are you a member of a Native American tribe?

YesNo

Unit and Station of Assignment:

Relationship Status:

Have you deployed? If so, where and when:

Address:

Street

City

State

Country

Zip

Home Phone:

Cell Phone:

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:

If not hospitalized, provide elements of Safeplan established for this intervention:

Was law enforcement involved?

YesNo

Point of contact for this report:

POC phone:

Critical Behavioral Health Incident Report (CBHIR)

Subject / Victim Information

Current Contact Information

Summary of Incident

Personal Information

Command Information