Incident Reporting Form

Mental health professionals are mandated by law to report abuse, neglect, suicidal or homicidal attempts, and sexual assault or abuse. Those situations require a Written Report for all of the situations above, Still Waters Professional Counseling, Inc. (SWPCI) requires any counselor or staff member who is aware of these situations to provide a Written Report of Mandated Reporter and a Critical Incident Form.

  • Important!

    The submission of this report does not take the place of your mandatory reporting capability. This form must be completed for any incident involving employees, consumers, and/or any other persons involved with employees or consumers, such as parents, siblings, or teachers.
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  • Incident Description

  • MM slash DD slash YYYY
  • Provide address and description of location.
  • Look over the description below and check the listing that best describes the incident. If none apply, select #16. Other Sentinel Event(s) and describe below.
  • Provide all details pertaining to the actual incident. Include as many accurate details as possible.

  • Individual(s) involved in Incident:

    List all individuals involved with the incident being reported.

  • Person Making the Report - Information