DEVELOPMENTAL DISABILITIES ADMINISTRATION (DDA) Cross System Crisis Plan TODAY’S DATE CLIENT’S NAME DATE OF BIRTH MENTAL HEALTH AGENCY TELEPHONE NUMBER MENTAL HEALTH AGENCY CASE MANAGER TELEPHONE NUMBER (Specify relationship) TELEPHONE NUMBER LEGAL REPRESENTATIVE / NSA NAME RESIDENTIAL SUPPORT AGENCY NAME TELEPHONE NUMBER ON-CALL NUMBER DDA CASE MANAGER/SOCIAL WORKER TELEPHONE NUMBER DDA MENTAL HEALTH LIAISON TELEPHONE NUMBER MH and Medical Diagnosis (DSM-5 Format) CONTRACT THERAPIST TELEPHONE NUMBER DOC CONTACT TELEPHONE NUMBER EMPLOYMENT/VOCATIONAL / SCHOOL CONTACT TELEPHONE NUMBER FAMILY CONTACT TELEPHONE NUMBER GENERAL PHYSICIAN / PRESCRIBER TELEPHONE NUMBER MH CRISIS TELEPHONE NUMBER DDA IR FAX NUMBER COMMUNICATION PREFERRED LANGUAGE Nonverbal English Verbal Sign Language Gestures Spanish Picture System Sound and Gestures Other Device: Challenges VISION HEARING MOBILITY EATING / SWALLOWING Contact for Updated Medication List NAME TELEPHONE NUMBER Risk Issues (For each box checked, briefly describe) Allergies (Food, Medication, Medical Conditions: Suicidal Ideation/Gestures: Aggression:
DEVELOPMENTAL DISABILITIES ADMINISTRATION (DDA) Cross System Crisis Plan TODAY’S DATE CLIENT’S NAME DATE OF BIRTH MENTAL HEALTH AGENCY TELEPHONE NUMBER MENTAL HEALTH AGENCY CASE MANAGER TELEPHONE NUMBER LEGAL REPRESENTATIVE / NSA NAME (Specify relationship) TELEPHONE NUMBER RESIDENTIAL SUPPORT AGENCY NAME TELEPHONE NUMBER ON-CALL NUMBER DDA CASE MANAGER/SOCIAL WORKER TELEPHONE NUMBER DDA MENTAL HEALTH LIAISON TELEPHONE NUMBER MH and Medical Diagnosis (DSM-5 Format) CONTRACT THERAPIST TELEPHONE NUMBER DOC CONTACT TELEPHONE NUMBER EMPLOYMENT/VOCATIONAL / SCHOOL CONTACT TELEPHONE NUMBER FAMILY CONTACT TELEPHONE NUMBER GENERAL PHYSICIAN / PRESCRIBER TELEPHONE NUMBER MH CRISIS TELEPHONE NUMBER DDA IR FAX NUMBER COMMUNICATION Nonverbal Gestures Sound and Gestures Verbal Picture System Other Device: PREFERRED LANGUAGE English Spanish Sign Language Challenges VISION HEARING MOBILITY EATING / SWALLOWING Contact for Updated Medication List NAME TELEPHONE NUMBER Risk Issues (For each box checked, briefly describe) Allergies (Food, Medication, Medical Conditions: Suicidal Ideation/Gestures: Aggression:
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