Support Line Record Form

CALL HANDLER NAME(required)

Clients First Name (required)

Clients Last Name(required)

If you are making an outgoing call, please insert here client already open to services otherwise complete in full.

Clients Phone Number(required)

Check client is resident at the address listed on the call schedule is this the case Yes

No – enter current location below

Clients First Line of Address(required)

Clients Post Code(required)

This call was (required) Incoming – the client called us

Outgoing – we called the client

If the call was outgoing – did they answer?(required) Yes

No NB you will need to put N/A for some other options lower on form

Not applicable

Does the client require a counselling referral to us? EXPLICITLY ASK THIS DO NOT MAKE ASSUMPTIONS(required) Yes – put their email in box below

No / They are already in counselling service / N/A

Email if client is going to counselling

Do they require further support line follow up calls? EXPLICITLY ASK THIS DO NOT MAKE ASSUMPTIONS(required) Yes – please agree these with the client and inform TL

No – support line call backs not required – N/A

CHECK FOR SUICIDE AND SELF HARM – ask the client if they are currently feeling suicidal or that they may hurt themselves(required) ZERO RISK – they have no thoughts or plans of self harm or suicide

LOW RISK – they have current or transient thoughts of suicide or self harm but not plan or intent

MEDIUM RISK – they have thoughts of self harm or suicide and there is a plan

HIGH RISK – they have thoughts of suicide or life threatening self harm, a plan and they have active intent

Client did not answer or call ended unexpectedly – could not assess risk

Details of any suicide or self harm risk, include here preventative measures you have undertaken, such as transfer to 111 or 999, or verbal advice, safe plan, etc If not applicable, enter not applicable. If not assessed put N/A(required)

NOTES – use this section to outline a brief summary of the call(required)