Due Sunday 10am
Virgo41
crisisassessmentform.docxTRIAGE 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.
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1 |
2 |
3 |
4 |
5 |
6 |
7 |
8 |
9 |
10 |
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No Impairment |
Minimal Impairment |
Low Impairment |
Moderate Impairment |
Marked Impairment |
Severe Impairment |
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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.
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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.
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1 |
2 |
3 |
4 |
5 |
6 |
7 |
8 |
9 |
10 |
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No Impairment |
Minimal Impairment |
Low Impairment |
Moderate Impairment |
Marked Impairment |
Severe Impairment |
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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.
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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.
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1 |
2 |
3 |
4 |
5 |
6 |
7 |
8 |
9 |
10 |
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No Impairment |
Minimal Impairment |
Low Impairment |
Moderate Impairment |
Marked Impairment |
Severe Impairment |
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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:
