Mental Health First Aid Incident Record
Incident Reporting Form
Please complete all the relevant sections of this form - mandatory fields are marked with an asterisk (required)
*
Section 1 - Person Reporting the Incident
Name of Mental Health First Aider (required)
*
Your Contact No./Email Address (required)
*
Date of Conversation (required)
*
Section 2 - Client Details
Client Name (optional)
Client Contact Number (optional)
Client Email Address (optional)
Status (desirable)
Please select
Staff
Student UG
Student PGT
Student PGR
Prefer not to say
Nature of stated/ presenting mental health issue(s) tick all that apply (required)
*
Suicidal Thoughts/Behaviour
Self-harming
Substance dependency
Depression
Anxiety
Psychosis
Unsure
Stress (Work-related)
Stress (Study-related)
Stress (Personal matter-related
Section 3 - ALGEE
Ask
Were you concerned the client could be suicidal at this time? (required)
*
Select
Yes
No
If Yes, did you ask the client if they were feeling suicidal? (required)
*
Select
Yes
No
If Yes, how did they respond - did they say that they felt suicidal? (required)
*
Select
Yes
No
If Yes, were you able to take measures to help keep the client safe? (required)
*
Select
Yes
No
Details (required)
*
Listen
Is the client currently receiving any other support for their issue(s)? (required)
*
Select
Yes
No
If Yes, what support are they receiving? (tick all that apply) (required)
*
Counselling CaPS
Counselling EAP
Counselling NHS
Counselling Private
GP
Approached Clinical Psychologist
Approached Psychiatrist
Approached Other
If Other, give details (required)
*
If the client had not met with the mental health first aider, what did they say they would have done? (Please tick all that apply)
*
Nothing
GP
Counselling CaPS
Counselling EAP
Counselling NHS
Counselling Private
CBT
Clinical Psychologist
Psychiatrist
Other
If Other, give details (required)
*
Give Information
What information was given to the client? (required)
*
Information on In-house support
Select
Yes
No
If Yes, give details (required)
*
Information on external services (required)
*
Select
Yes
No
If Yes, give details (required)
*
Self-help options (required)
*
Select
Yes
No
If Yes, give details (required)
*
Encourage appropriate professional help
Did the client say they intended to get help? (required)
*
Select
Yes
No
If Yes, give details (required)
*
Encourage self-help and other strategies
Did the client say they intended to take up self-help options? (required)
*
Select
Yes
No
If Yes, give details (required)
*
Section 4 - Self Care for MHFA
How are you, the MHFA, following this interaction?
Select
Very comfortable with the outcome
Fairly comfortable with the outcome
Unsure about the outcome
Concerned about the outcome
Worried about the outcome
Do you feel you would like some support following this interaction?
Select
Yes
No
If yes, are you happy to contact in-house/ external support yourself?
Select
Yes
No
If no, would you like some help accessing support?
Select
Yes
No
If Yes, please provide your preferred contact details
Press "Submit Form" button once you've completed the form
Submit Form