Florida School Toolkit for K-12 Educators to Prevent Suicide

TOOL 28b Documentation Form for Community-Based Mental Health Facilities and Providers Item Rating (1–3) Notes Response time Communication effectiveness Care coordination Follow-up Student satisfaction Parent satisfaction Incident:__________________________________ Start Date:__________ End Date:__________ Item Rating (1–3) Notes Response time Communication effectiveness Care coordination Follow-up Student satisfaction Parent satisfaction Incident:__________________________________ Start Date:__________ End Date:__________ Item Rating (1–3) Notes Response time Communication effectiveness Care coordination Follow-up Student satisfaction Parent satisfaction Incident:___________________________________ Start Date:__________ End Date:_________ Completed by:______________________________________________ Date:_ _________________ Facility/Provider:____________________________ Contact Name:_ ___________________________ Address:______________________________________________________ Phone:_ _____________ Email:____________________________ Provides Transportation for Suicidal Individuals (Y/N):_ _____ Past Experience Summary:_____________________________________________________________ _________________________________________________________________________________ Interaction Documentation Rating: Unsatisfactory=1, Needs Improvement=2, Satisfactory=3 Florida S.T.E.P.S.