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Intervention Checklist Worksheet

Amanda Knowles
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On this page we will provide you with an Intervention Checklist Worksheet It will help you 

Well prepared to deal with  any kind of emergency situations.

What is the Intervention Checklist Worksheet?

In order to ensure your safety and the people around you, you create an intervention checklist, just to protect yourself from any kind of emergency situation. Intervention checklist  includes a written set of instructions to be followed at the time of emergency. It will have a series of gradually escalating steps that you will follow, proceeding from one step to the next, until you feel controlled, calm and safe. It will have a safety plan, clinician notes and reasons sof a referral.

How an Intervention Checklist Worksheet will help?

When you are at risk of suicide, self-harm or any other serious emergency situation but haven’t reached the level of severity required for involuntary hospitalization, it's common practice to create a an intervention checklist that has a safety plan and a number of instructison sto follow whenever get encountedred with  difficult situation. It is actually a contingency plan that you prepare for yourself whenever you are headed towards a crisis.

Instructions on how to use the Intervention Checklist Worksheet

Use this worksheet to help yourself by creating an intervention Checklist.

You can download this worksheet here.

Other worksheets you maybe interested in 

Below are links to a few more worksheets which are closely related to the worksheet above.

Functional Analysis With Intervention Planning Worksheet

Three Common Principles of Effective Behavioral Interventions and the Relationship to Person-Centered Needs worksheet



On this page we provided you with an Intervention Checklist Worksheet which hopefully helped you well prepared to deal with  any kind of emergency situations.

If you have any questions or comments please let us know.


The worksheets on this site should not be used in place of professional advice from a mental health professional. 

You should always seek help from a mental health professional or medical professional. We are not providing any advice or recommendations here.

There are various resources where you can seek help.

You could use Online-Therapy if you feel you need counselling.

If you live in the UK then this list of resources from the NHS may help you find help.

If you live in the USA then you could contact Mental Health America who may be able to assist you further.

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Amanda Knowles

Amanda Knowled is an Applied Psychologist, with a deep interest in psychopathology and neuropsychology and how psychology impacts and permeates every aspect of our environment. She has worked in Clinical settings (as Special Ed. Counselor, CBT Therapist) and has contributed at local Universities as a Faculty member from time to time. She has a graduate degree in English Literature and feels very connected to how literature and psychology interact. She feels accountable and passionate about making a "QUALITY" contribution to the overall global reform and well-being. She actively seeks out opportunities where she can spread awareness and make a positive difference across the globe for the welfare of our global society.