. Read the Case Study Scenario. Complete a Triage Assessment on Tom using the Triage Assessment Form. Use the end of the form to address the following items: Identify one action strategy that provides

Crisis Date: ___________________ Office Visit Date: ____________________

Family Members: Name, Age, and Role (present and not present)_____________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

Crisis Description __________________________________________________________________________________

_________________________________________________________________________________________________

Attempt/s at Resolution: _____________________________________________________________________________

__________________________________________________________________________________________________

Observations and Reported Behaviors (Check as many that apply)

___ inability to provide daily needs (___food

___clothing ___shelter ___ utilities)***

___ self-medication by one or more members

___ major health concerns reported *

___ family violence ***

___ neglect of children (emotional, physical)***

___ verbal threats to self or others

___ suicidal/homicidal thinking/verbalizing *

___ suicidal/homicidal gestures/behaviors *

___ suicidal/homicidal plan clear *

___ disagreements within family

___ family members disengaged

___ lack of energy within family

___ isolation from social support systems

___ approval seeking by family members

___ refusal to communicate with other family members

___ demanding special attention by family members

___ tension among family members

___ denial by family members

___ family members nonresponsive

___ family members responses guarded

Notes: ____________________________________________________________________________

__________________________________________________________________________________

***Referral to Social Service Recommended *Referral for Specialized Support

Triage Assessment

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 suggesting family resiliency.

• Brief periods of elevated negative mood with little effect on family resiliency.

• Evidence of negative mood noticeable causing family resiliency to fluctuate.

• Mood primarily negative causing family resiliency to be ineffectual.

• Mood is negative causing family resiliency to be fail.

• Mood is shutting down ability to respond to the crisis causing family resiliency to disappear.

• Affect is appropriate with no effect on boundaries.

• Affect elevated but generally appropriate with little effect on boundaries.

• Affect intensity is longer than situation warrants causing boundary disruptions.

• Affect control is difficult and not always successful causing changes in boundaries.

• Affected not controlled with significant boundary shifts.

• Affect control absent causing danger to family or others and boundaries to be ignored.

• Emotions are under control with no impact on family values.

• Emotions are substantially under control with no effect on family values.

• Emotions are controlled but influenced by crisis with minimal effect on family values.

• Emotions not under control and focused on crisis and influencing family values.

• Emotions generalize from crisis event to other situations and changing family values.

• Emotions of the crisis are generalized to situations substantially changing family values.

• 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.

• 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
A
L

• Behaviors are socially appropriate.

• Behaviors mostly effective, outbursts if present are inconsequential.

• Behaviors are ineffective, yet not dangerous.

• Behaviors are maladaptive but not immediately destructive.

• Behaviors are likely to intensify crisis situation.

• Behaviors are ineffective and accelerate the crisis.

• Family rules unaffected.

• Family rules mostly followed.

• Family rules recognized but adjusted.

• Family rules altered.

• Family rules suspended.

• Family rules abandoned.

• Daily routine unimpeded.

• Daily routine mostly followed with minimal effort.

• Daily routine experiencing periodic disruptions.

• Daily routine noticeably compromised.

• Daily routine experiencing significant disruptions.

• Daily functioning not preformed.

• Behaviors are not a threat or danger nonexistent.

• Behaviors demonstrates frustration, but is nonthreatening.

• Behaviors minimal threat to family or others.

• Behaviors are a potential threat to family or others.

• Behaviors are impulsive and harmful to family or others.

• Behaviors are highly destructive possibly to cause injury/death to family or others.

C
OGN
I
T
I
V
E

• Roles are stable.

• Roles mostly stable but still functional for daily living.

• Roles fluctuating but still functional for daily living.

• Roles fluctuating and not functional for daily living.

• Role overlap interrupts functioning for daily living.

• Role breakdown prevents functioning for daily living.

• Decisions are considerate of family members.

• Decisions are not consistently considerate of family members.

• Decisions are inconsiderate of family members.

• Decisions are arbitrary and antagonistic of family members.

• Decisions are random with a potential to be harmful to family members

• Decisions are a clear and present danger to family members.

• Decisions are logical and reasonable.

• Decisions are indecisive but only with respect to crisis.

• Decisions are inconsistent and sometimes unreasonable.

• Decisions are erratic and reality and interfering with daily functioning.

• Decisions are illogical, have little basis in and generalized beyond crisis.

• Decision making frenetic or frozen and not based in reality and shuts down daily functioning.

• Discussion of crisis event substantially matches reality with communication being normal within the family.

• Discussion influenced by crisis, but communication not effected.

• Discussion focused on crisis but with prompting still able to consider other issues within family.

• Discussion is limited to crisis situation disrupting communication within family.

• Discussion about crisis intrusive to communication within family.

• Discussion is chaotic shutting down communication within the family.

• Accept views of others in family.

• Acknowledge views of others in family.

• Acknowledging views of others in family difficult.

• Disagreement with views of others in family.

• Antagonistic of views of others in family.

• Aggressively confronting views of others.

• Problem solving strategy agreed on.

• Problem solving agreed on with minimal dissent.

• Problem solving inconsistency within family.

• Problem solving disputed with no agreement.

• Problem solving argued with no consensus.

• Problem solving not observable with no ability to focus.