START Summary Sheet - BC Mental Health and Substance Use

Record #. Male □ Female □ D.O.B: ______. START Summary Sheet. ©. Diagnoses: DSM-V □. ICD-10 □. 1. 2. 3. 4. 5. STATUS: □ HOSPITAL. □ COMMUNITY.
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Name: _______________________________ Last

First

Middle

Record # _____________________________ Male 

D.O.B: _____________

Female 

START Summary Sheet © DSM-V 

ICD-10 

1

________________________

4

Diagnoses: 3

STATUS: PURPOSE:

________________________ ________________________

 HOSPITAL

 COMMUNITY

Status: _____________________

Status: _____________________

 REFERRAL

 ADMISSION

2 5

_____________________ _____________________

 CORRECTIONS Status: _____________________

 REVIEW

 OTHER

Specify: _____________________

Specify: ____________________

START Time Frame: __________________________________ days / weeks / months Key Item

2

Strengths 1 0

Vulnerabilities 0 1 2

START Items

Critical Item

SIGNATURE RISK SIGNS









1.

Social Skills

















2.

Relationships (TA:Y/N)*

















3.

Occupational









  

  

  

  

4.

Recreational

  

  

  

Hx

Risks



Violence

No 

Yes















Self-Harm

No 

Yes 











No 

Yes 







  

5.

Self-Care

6.

Mental State

  



7.

Emotional State















8.

Substance Use









 Suicide

  

  

Impulse Control  9. External Triggers  10.  11. Social Support (PPS:Y/N)‡

  

  

  

  

 Unauthorized Leave  Substance Abuse  Self-Neglect

  

  

  







 12.

Material Resources















 13.

Attitudes









 

 

 

 









____________________

 

 

 

CURRENT MANAGEMENT MEASURES









 14. Med. Adherence (N/A )

 

 

 

 15.  16.

Rule Adherence Conduct

 







 17.

Insight









  

  

  

 18.  19.  20.

Plans

  

  

  

  

































Coping

Treatability Case Specific: 21. ______________ Case Specific: 22. ______________

SPECIFIC RISK ESTIMATES ♦

T.H.R.E.A.T.

Being Victimized Case Specific:

Low

Mod High

Current Management Plan:

Health Concerns/Medical Tests:

Risk Formulation: what factors/predict-explain/which person/will carry out/what act/when?

Completed by (Pls print): ________________________________________________________________ Date:_________________ *TA - Therapeutic Alliance



PPS - Positive Peer Support



N/A – Not Applicable



Hx - Historical

Version 1.3 © 2014