Describe the observations that led you to check the characteristics above

Describe the observations that led you to check the characteristics above

Client Name: ____________________________________________ Time/Date: __________________

Crisis Worker: _________________________ Contact Type: __________ Phone: _______ Office: _______

Field

Crisis Event:

___________________________________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

Disposition:

__________________________________________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

 

Observations (Check as many that apply)

___ off medication*

___ medication not effective***

___ hallucinating*** (___smells___ sights___sounds___touch)

___ bizarre behavior/appearance

___ poor hygiene

___ absurd, illogical speech***

___ paranoid/suspicious thoughts***

___ 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

___ self-injurious behavior

___ physically violent*

___ verbal threats to self or others

___ suicidal/homicidal thinking/verbalizing

___ 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

Figure 3.2 Triage Assessment Form for Crisis Intervention.

SOURCE: Compiled from Triage Assessment Form (TAF), Triage Assessment System for Students in Learning Environments (TASSLE), Triage Assessment Checklist for Law Enforcement (TACKLE). Crisis Intervention & Preventions Solutions Inc.

Pittsburgh, PA.

SEVERITY SCALES

Check those that apply

  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.

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 with #1 being primary, #2 secondary, #3 tertiary.)

ANGER/HOSTILITY:

ANXIETY/FEAR:

SADNESS/MELANCHOLY:

FRUSTRATION:

BEHAVIORAL DOMAIN

Identify and describe briefly which behavior is currently being used. (If more than one behavior is utilized, rate with #1 being primary, #2 secondary, #3 tertiary.)

APPROACH:

AVOIDANCE:

IMMOBILITY:

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 with #1 being primary, #2 secondary, #3 tertiary.)

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

Transgression_____ Threat_____ Loss______

PSYCHOLOGICAL (self-concept, sense of emotional well-being, ego integrity, self-identity, etc.):

Transgression_____ Threat______ Loss______

SOCIAL RELATIONSHIPS (positive interaction and support, family, friends, coworkers, church, clubs, etc.):

Transgression______ Threat______ Loss______

MORAL/SPIRITUAL (personal integrity, values, belief system, spiritual reconciliation):

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)

 

Transgression______ Threat______ Loss______

Describe the observations that led you to check the characteristics above:

_____________________________________________________

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