Describe the observations that led you to check the characteristics above
Describe the observations that led you to check the characteristics aboveClient Name: ____________________________________________ Time/Date: __________________ Crisis Worker: _________________________ Contact Type: __________ Phone: _______ Office: _______ Field Crisis Event: ___________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ Disposition: __________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________
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| 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 |
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| 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. |
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· 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. |
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· 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.
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· 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. |
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· 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. |
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· 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. |
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· 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. |
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· 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)
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Transgression______ Threat______ Loss______
Describe the observations that led you to check the characteristics above:
_____________________________________________________
