Form Crisis Center Data Crisis Center Data Crisis Center Data Abstraction Form

Crisis Center Data Abstraction Form

OMB No. XXXX-XXXX

                                                                                                                                Expiration Date: Month Year

Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.  The OMB control number for this project is XXXX-XXXX.  Public reporting burden for this collection of information is estimated to average 2 minutes per client per year, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.  Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to SAMHSA Reports Clearance Officer, 1 Choke Cherry Road, Room 2-1057, Rockville, Maryland, 20857.

1. Patient ID:

2. Date of Referral from Hospital: ____________________

3. Clinical Contact Made?  Yes  No

If yes:

3a. Date(s) of Clinical Contact: _____________________________________________