24-HR CRISIS LINE 844-345-4569 (Clay, Osceola and Palo Alto Counties)

24-HR CRISIS LINE 855-581-8111 (Kossuth, Winnebago and Worth Counties)

Call or text 988 for the Suicide and Crisis Lifeline

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Secure Transportation Questionnaire

This form is for authorized personnel only

Step 1 of 3

33%

Client Name(Required)

First Last

Date of Birth(Required)

Starting Location(Required)

Street Address Address Line 2 City State ZIP Code

Dropoff Location(Required)

Street Address Address Line 2 City State ZIP Code

Client Home Address(Required)

Street Address Address Line 2 City State ZIP Code

Does the individual have their own vehicle or method of transportation?(Required)

Yes

No

Does the individual wish to transport themselves privately?(Required)

Yes

No

Does the individual have natural support that can provide transportation?(Required)

Yes

No

Does the individual have the means to pay for a private taxi or transportation?(Required)

Yes

No

Does the admitting Crisis Provider have the means to transport the individual?(Required)

Yes

No

Please explain:(Required)

(To be eligible for secure transport, at least one of the two boxes below must be checked Yes.)

Is there an immediate risk to run away, a history of serious behavior, or a previous runaway?(Required)

Yes

No

Have recent behaviors indicated a person may be at risk for their own safety?(Required)

Yes

No

Check all that apply(Required)

Self-harming gestures with voiced intent to continue to self-harm

Voiced intent to engage in suicidal behavior Choice

Suicide attempt made

Agitated and/or out of control

Threatening to leave a moving vehicle

History of leaving or attempting to leave the vehicle

For Children:

Yes

No

Please indicate in the space below why parents and/or guardians are unable to transport.

Has the parent/guardian and/or referring agency contacted community resources or assistance?

Yes

No

(For example, gas voucher)

Please explain:

What is the plan for client discharge transportation?(Required)

Regional billing to:(Required)

Care Connections

Rolling Hills

Sioux Rivers

Person Completing Form(Required)

First Last

Phone(Required)

Email(Required)

Supplemental Information that may be relevant:

By checking this box, I confirm that I am authorized to submit this form on behalf of my agency. I understand that submitting this form will not arrange transportation and that arrangements must still be made with the transport center by phone.(Required)

I agree and confirm

Resources

Helpful Links

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Mental Health Advocate

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Virtual Calming

Trinity Rocks
Calming Room
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