Week 3 Discussion Response to Classmates

Client Name: Amy__________________________________________ Time/Date: 5:30pm / 09-12-18__________

Crisis Worker: Alberta Riptoe__________________ Contact Type: Individual___ Phone: _______ Office: 1024__

Field

Crisis Event:

Client is seeking counseling due to self-reported anxiety symptoms.

______________________________

_______________________________________________________________________________________________

Disposition:

Excessive worry, feelings of impending doom and fear.___________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

Observations (Check as many that apply)

___ off medication*

___ medication not effective***

___ hallucinating*** (___smells___ sights___sounds___touch)

___ bizarre behavior/appearance

___ poor hygiene

___ absurd, illogical speech***

_X paranoid/suspicious thoughts***

_X flashbacks, loss of reality contact

___ intoxicated/drugged*

___ under the influence of mood-altering substance

___ other (explain)

___ oppositional defiant to verbal suggestions

___ coercion/intimidation

___ aggressive gestures*

___ reckless behavior

_X self-injurious behavior

___ physically violent*

___ verbal threats to self or others

___ suicidal/homicidal thinking/verbalizing

_X suicidal/homicidal gestures/behaviors*

___ suicidal/homicidal plan clear*

___ uncooperative

___ flat affect

___ impulsivity

___ hysterical

___ confusion

___ unable to follow simple directions

___ unable to control emotions

___ cannot recall personal information (phone, address)

___ situation perceived as unreal (spectator)

___ nonresponsive***

Notes:

_____________________________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________________

*** psychiatric evaluation recommended * hold for law enforcement officers or EMTs

1

No

Impairment

2/3

Minimal

Impairment

4/5

Low

Impairment

6/7

Moderate

Impairment

8/9

Marked

Impairment

10

Severe

Impairment

A F F E C T I V E

· Stable mood, control of feelings.

· Affect elevated but generally appropriate.

· Evidence of negative feelings pronounced and increasingly inappropriate.

· Feelings are primarily negative and are exaggerated or increasingly diminished.

· Feelings are negative and highly volatile or may be nonexistent.

· Feelings are extremely pronounced to being devoid of feeling.

· Feelings are appropriate.

· Brief periods of slightly elevated negative mood.

· Duration of feeling intensity longer than situation warrants.

· Efforts to control emotions are not always successful.

· Extremely limited control of emotions.

· No ability to control feelings regardless of potential danger to self or others.

· Emotions are under control.

· Emotions are substantially under control.

· Emotions are controlled but focused on crisis event.

· Emotions not under control but remain focused on crisis.

· Emotions start to generalize from crisis event to other people and situations.

· Emotions of the crisis are generalized to other people and situations.

· Responses to questions/ requests are calm and composed.

· Responses to questions/ requests are emotional but composed.

· Responses to questions/ requests vary from rapid and agitated to slow and subdued.

· Responses to questions/ requests are emotionally volatile or beginning to shut down.

· Responses to questions/ requests noncompliant due to interference of emotions.

· Cannot respond to questions/ requests because of interference of emotions.

B E HA V I OR S

· Behaviors are socially appropriate.

· Behaviors are mostly effective; outbursts, if present, are inconsequential.

· Behaviors are somewhat ineffective yet not dangerous.

· Behaviors are maladaptive but not immediately destructive.

· Behaviors are likely to intensify crisis situation.

· Behaviors are totally ineffective and accelerate the crisis.

· Daily functioning is unimpeded.

· Can perform tasks needed for daily functioning with minimal effort.

· Performance of tasks needed for daily living is minimally compromised.

· Performance of tasks needed for daily living is noticeably compromised.

· Ability to perform tasks needed for daily functioning is seriously impaired.

· Unable to perform even simple tasks needed for daily functioning.

· Threat or danger is nonexistent.

· Behavior demonstrates frustration but is nonthreatening.

· Behaviors are a minimal threat to self or others.

· Behavior is a potential threat to self or others.

· Impulsivity has the potential to be harmful to self or others.

· Behaviors are highly destructive and could possibly cause injury/death to self or others.

· Behavior is stable and non-offensive.

· Behaviors mostly stable and non-offensive.

· Behavior is becoming unstable and offensive.

· Upon request, behaviors can be controlled with effort.

· Behaviors are very difficult to control, even with repeated requests.

· Behavior is out of control and nonresponsive to requests.

C OGN I T V E

· Decisions are considerate of others.

· Decisions may not be considerate of others.

· Decisions are inconsiderate of others.

· Decisions are offensive and antagonistic of others.

· Decisions have the potential to be harmful to self or others.

· Decisions are a clear and present danger to self and others.

· Decisions are logical and reasonable.

· Decisions are becoming indecisive but only with respect to crisis.

· Decisions are becoming illogical, unreasonable, and generalized beyond crisis.

· Decisions about crisis are beginning to interfere with general functioning.

· Decisions are illogical and have little basis in reality, and general functioning is compromised.

· Decision making is frenetic or frozen and not based in reality and shuts down general functioning.

· Perception of crisis event substantially matches reality.

· Thinking is influenced by crisis but is under control.

· Thinking is focused on crisis but is not all consuming.

· Thoughts are limited to crisis situation and are becoming all consuming.

· Thoughts about crisis have become pervasive.

· Thoughts are chaotic and completely controlled by crisis.

· Able to carry on reasonable dialog and understand and acknowledge views of others.

· Able to carry on reasonable dialog and understand and acknowledge views of others.

· Ability to carry on reasonable dialog restricted and has problems understanding and acknowledging views of others.

· Responses to questions and requests are restricted or inappropriate and denies understanding views of others.

· Is defiant to requests and questions and/or inappropriate with and antagonistic of others.

· Requests and questions are believed as threats and responded to aggressively.

· Problem solving is intact.

· Problem solving is minimally compromised.

· Problem solving is limited.

· Problem solving is blocked.

· Problem solving ability is absent.

· Problem solving is not observable with no ability to concentrate.

TRIAGE ASSESSMENT (X = Initial Assessment/O = Terminal Assessment)

Affective

___ Anger ___ Fear ___ Sadness

( (

1 2 3 4 5 6 7 8 9 10

Behavioral

___ Approach ___ Avoidance ___ Immobile

( (

1 2 3 4 5 6 7 8 9 10

Cognitive

___ Transgression ___Threat ___Loss

( (

1 2 3 4 5 6 7 8 9 10

______ Physical _______ Psychological _______ Relationship _______ Moral/Spiritual

Initial Total Score: _________ Terminal Total Score: _________ (if used)