After having my first truly white-knuckled experience with a psychiatric emergency in my own practice, I'm going over my policy and procedure manual and reviewing it. I worked for 8 years in community mental health emergency services, with a well-known emergency services agency, and so the system was pretty clear cut and if there was any dispute, we each had a ceo to call and have them fight it out. But now I'm dealing with a crisis center that in my experience in the past has been inconsistent with policies and procedures, and my practice is in their county, and they're the ones I have to deal with in an emergency. To generally describe the inconsistency, the first time I called to consult them, when I felt the risk was low to moderate, and they wanted to send someone out to the house and bring her in to their center. I went ahead with a safety plan that included close monitoring (no small number of unbillable hours I realized) and then a week later I felt it was a true emergency, and I called them when the situation was going on in my office I wanted them to come evaluate and they felt it wasn't "appropriate for them to go out there" and wanted me to send the client to their center (after dark, to a questionable neighborhood). So I'm kind of scratching my head about this. I've been considering trying to set up a meeting with them to see what the protocol is in this county, and truthfully to see if I can pin them down on a few policies.

I'm evaluating my approach to taking on clients. At this time, I'm just starting out and my case load is low and I can afford this extra unpaid time, but once I get more clients I know I won't be able to. I discussed this issue with a psychologist who advised an initial consultation (which I offer for free) and evaluate them for impulsivity and appropriateness of boundaries. I'm exploring other issues that should be taken into consideration as well. This just drove home the point about how different this landscape is than agency counseling. Fortunately all turned out well, I got great support from the family physician's nurse.

so, in the interest of balancing out client rights with client safety, I'd be interested to hear from other clinicians, especially those in solo practice, on what their criteria and personal decision tree includes in terms of client suicide risk, as far as when do you do a safety plan, what are some measures you've put on a safety plan, at what point do you move to involuntarily hospitalize, and at what point do you get heavy handed and involve the police?(because that's where I was almost at at one point in all this)