TRIAGE ASSESSMENT FORM: CRISIS INTERVENTION 8 R.A. Myer, R.C. Williams, A.J. Ottens, & A.E. Schmidt

TRIAGE ASSESSMENT FORM: CRISIS INTERVENTION

8 R.A. Myer, R.C. Williams, A.J. Ottens, & A.E. Schmidt

CRISIS EVENT:

Identify and describe briefly the crisis situation:

AFFECTIVE DOMAIN

Identify and describe briefly the affect that is present. (If more than one affect is experienced, rate them in priority order.)

ANGER/HOSTILITY:

ANXIETY/FEAR:

SADNESS/MELANCHOLY:

__________________________________________________________________________________________________

Affective Severity Scale1

Circle the number that most closely corresponds with client’s reaction to crisis.

1 2 3 4 5 6 7 8 9 10
No

Impairment

Minimal

Impairment

Low

Impairment

Moderate

Impairment

Marked

Impairment

Severe

Impairment

Stable mood with normal variation or affect appropri-ate to daily functioning. Affect appropriate to situation. Brief periods during which negative mood is experienced slightly more intensely than situation warrants. Emotions are substan-

tially under client control.

Affect appropriate to situation, but increasingly longer periods during which negative mood is experienced slightly more intensely than situation warrants. Client perceives emotions as being substantially under control. Affect may be incon-

gruent with situation. Extended periods of intense negative moods. Mood is experienced noticeably more intensely than situation warrants. Lability of effect may be present. Effort required to control emotions.

Negative affect experi-enced at markedly higher level than situation warrants. Affects may be obviously incon-

gruent with situation. Mood swings, if occurring, are pronounced. Onset of negative moods are perceived by client as not being under volitional control.

Decompensation or depersonalization evident.

Triage Assessment Form: Crisis Intervention

BEHAVIORAL DOMAIN

Identify and describe briefly which behavior is currently being used. (If more than one behavior is utilized, rate in priority order)

APPROACH:

AVOIDANCE:

IMMOBILITY:

Behavioral Severity Scale

Circle the number that most closely corresponds with client’ reaction to crisis.

1 2 3 4 5 6 7 8 9 10
No

Impairment

Minimal

Impairment

Low

Impairment

Moderate

Impairment

Marked

Impairment

Severe

Impairment

Coping behavior appropriate to crisis event. Client performs those tasks necessary for daily functioning. Occasional utilization of ineffective coping behaviors. Client per-

forms those tasks necessary for daily functioning, but does so with noticeable effort.

Occasional utilization of ineffective coping behaviors. Client neglects some tasks necessary for daily functioning, performs others with decreasing effectiveness. Client displays coping behaviors that may be ineffective and mal-adaptive. Ability to perform tasks neces-

sary for daily func-tioning is noticeably compromised.

Client displays coping behaviors that are likely to exacerbate crisis situation. Ability to perform tasks necessary for daily functioning is markedly absent. Behavior is erratic, unpredictable. Client=s behaviors are harmful to self and/or others.

Triage Assessment Form: Crisis Intervention (continued)

COGNITIVE DOMAIN

Identify if a transgression, threat, or loss has occurred in the following areas and describe briefly. (If more than one cognitive response occurs, rate in priority order.){Transgression=something bad is happening in the present moment; Threat=something bad will happen; Loss=something bad has occurred.}

PHYSICAL (food, water, safety, shelter, etc.):

TRANSGRESSION THREAT LOSS

PSYCHOLOGICAL (self-concept, emotional well being, identity, etc.):

TRANSGRESSION THREAT LOSS

SOCIAL RELATIONSHIPS (family, friends, co-workers, etc.):

TRANSGRESSION THREAT LOSS

MORAL/SPIRITUAL (personal integrity, values, belief system, etc.):

TRANSGRESSION THREAT LOSS

Cognitive Severity Scale

Circle the number that most closely corresponds with clients reaction to crisis.

1 2 3 4 5 6 7 8 9 10
No

Impairment

Minimal

Impairment

Low

Impairment

Moderate

Impairment

Marked

Impairment

Severe

Impairment

Concentration intact. Client displays normal problem-solving and decision-making abilities. Clients perception and interpretation of crisis event match with reality of situation. Clients thought may drift to crisis event but focus of thoughts is under volitional control. Problem-solving and decision-making abilities minimally affected. Clients perception and interpretation of crisis event substantially match with reality of situation. Occasional disturbance of concentration. Client perceives diminished control over thoughts of crisis event. Client experiences recurrent difficulties with problem-solving and decision-making abilities. Clients per-ception and interpreta-tion of crisis event may differ in some respects with reality of situation. Frequent disturbance of concentration. Intrusive thoughts of crisis event with limited control. Problem solving and decision-making abilities adversely affected by obsessiveness, self-doubt, confusion. Clients perception and interpretation of crisis event may differ noticeably with reality of situation. Client plagued by intrusiveness of thought regarding crisis event. The appropriate-ness of clients problem-solving and decision-making abilities likely adversely affected by obsessiveness, self-doubt, confusion. Clients perception and interpretation of crisis event may differ substantially with reality of situation. Gross inability to concentrate on anything except crisis event. Client so afflicted by obsessiveness, self-doubt, confusion that problem-solving and decision-making abilities have shut down. Clients perception and interpretation of crisis event may differ so substantially from reality of situation as to constitute threat to clients welfare.

DOMAIN SEVERITY SCALE SUMMARY – Transfer the highest Number when you circled the number that most closely corresponded with clients reaction to crisis in all 3 of these areas:

Affective

Behavioral

Cognitive _____

Total _____

Triage Assessment Form: Crisis Intervention (continued)

Additional Notes:

 

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