Please no plagiarism and make sure you are able to access all resource on your own before you bid. One of the references must come from James, R. K., & Gilliland, B. E. (2017). I have put in bold the

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

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: Amy is really worried about the panic attacks that she has when she goes to school. She has flashbacks that are physically and emotionally paralyzing when she is school around a lot of students.

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: She still smiles and can have conversation but she is frustrated by the fact that she has these panic attacks because she feels that it is preventing her from having a relationship with a man.

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:

______________________________________________________________________________________