Central Minnesota EMS Region Critical Incident Stress Management by elfphabet5

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									                                Central Minnesota EMS Region 

                        Critical Incident Stress Management Services 

                                   Intervention Report Form 

                           (To be used by Team Leader/Debriefing Leader) 



Description of Incident:



Incident Date:_______________________                Debriefing Date:__________________
Location of Intervention:
Team Leader:

Mental Health Professional:
Peer(s):


Number of Participants: ______________ 


General Impressions of the Interventions: 





Need for Additional Services:




Follow-up Services by Whom:

Follow-up Contact Name & Number:

Additional Comments:




Signature of Team Leader:

Mail to: 	    Central MN EMS Region
              705 Courthouse Square
              St. Cloud, MN 56330



Central MN EMS Region, 705 Courthouse Square, St. Cloud, MN 56303
Phone: (320) 656-6122 Fax: (320) 656-6130 Web: www.co.stearns.mn.us/departments/ems
                                                                                      Updated 10/06

								
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