Crisis Intervention
Triage Assessment Form: Crisis Intervention
© by R. A. Myer, R. C. Williams, A. J. Ottens, & A. E. Schmidt
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 number 1 being primary, number 2 secondary, number 3 tertiary.)
Anger/Hostility ____________________________________________________________________________________________________________________________________________________
Anxiety/Fear ____________________________________________________________________________________________________________________________________________________
Sadness/Melancholy ____________________________________________________________________________________________________________________________________________________
Affective Severity Scale
Highlight the number that most closely corresponds with client’s reaction to crisis.
| 1 | 2 3 | 4 5 | 6 7 | 8 9 | 10 |
| No Impairment | Minimal Impairment | Low Impairment | Moderate Impairment | Marked Impairment | Severe Impairment |
| Stable mood with normal variation of affect appropriate to daily functioning. | Affect appropriate to situation. Brief periods during which negative mood is experienced slightly more intensely than situation warrants. Emotions are substantially under client control. | Affect appropriate to situation but increasingly longer periods during which negative mood is experienced slightly more intensely than situation warrants. Client perceives emotions as being substantially under control. | Affect may be incongruent with situation. Extended periods of intense negative moods. Mood is experienced noticeably more intensely than situation warrants. Liability of affect may be present. Effort required to control emotions. | Negative affect experienced at markedly higher level than situation warrants. Affects may be obviously incongruent with situation. Mood swings, if occurring, are pronounced. Onset of negative moods are perceived by client as not being under volitional control. | Decompensation or depersonalization evident. |
Behavioral Domain
Identify and describe briefly which behavior is currently being used. (If more than one behavior is used, rate with number 1 being primary, number 2 secondary, number 3 tertiary.)
Approach ____________________________________________________________________________________________________________________________________________________
Avoidance ____________________________________________________________________________________________________________________________________________________
Immobility ____________________________________________________________________________________________________________________________________________________
Behavioral Severity Scale
Highlight the number that most closely corresponds with client’s reaction to crisis.
| 1 | 2 3 | 4 5 | 6 7 | 8 9 | 10 |
| No Impairment | Minimal Impairment | Low Impairment | Moderate Impairment | Marked Impairment | Severe Impairment |
| Coping behavior appropriate to crisis event. Client performs those tasks necessary for daily functioning. | Occasional use of ineffective coping behaviors. Client performs those tasks necessary for daily functioning, but does so with noticeable effort. | Occasional use of ineffective coping behaviors. Client neglects some tasks necessary for daily functioning. | Client displays coping behaviors that may be ineffective and maladaptive. Ability to perform tasks necessary for daily functioning is noticeably compromised. | Client displays coping behaviors that are likely to exacerbate crisis situation. Ability to perform tasks necessary for daily functioning is markedly absent. | Behavior is erratic, unpredictable. Client’s behaviors are harmful to self and/or others. |
Cognitive Domain
Identify whether a transgression, threat, or loss has occurred in the following areas and describe briefly. (If more than one cognitive response occurs, rate with number 1 being primary, number 2 secondary, number 3 tertiary.)
PHYSICAL (food, water, safety, shelter, et cetera):
Transgression _____ Threat _____ Loss _____
____________________________________________________________________________________________________________________________________________________
PSYCHOLOGICAL (self-concept, emotional well-being, identity):
Transgression _____ Threat _____ Loss _____
____________________________________________________________________________________________________________________________________________________
SOCIAL RELATIONSHIPS (family, friends, coworkers, et cetera):
Transgression _____ Threat _____ Loss _____
____________________________________________________________________________________________________________________________________________________
MORAL/SPIRITUAL (personal integrity, values, beliefs):
Transgression _____ Threat _____ Loss _____
____________________________________________________________________________________________________________________________________________________
Cognitive Severity Scale
Highlight the number that most closely corresponds with client’s reaction to crisis.
| 1 | 2 3 | 4 5 | 6 7 | 8 9 | 10 |
| No Impairment | Minimal Impairment | Low Impairment | Moderate Impairment | Marked Impairment | Severe Impairment |
| Concentration intact. Client displays normal problem-solving and decision-making abilities. Client’s perception and interpretation of crisis event match reality of situation. | Client’s thoughts may drift to crisis event but focus of thoughts is under volitional control. Problem-solving and decision-making abilities minimally affected. Client’s perception and interpretation of crisis event substantially match reality of situation. | Occasional disturbance of concentration. Client perceives diminished control over thoughts of crisis event. Client experiences recurrent difficulties with problem-solving and decision-making abilities. Client’s perception and interpretation of crisis event may differ in some respects from reality of situation. | Frequent disturbance of concentration. Intrusive thoughts of crisis event with limited control. Problem-solving and decision-making abilities adversely affected by obsessiveness, self-doubt, confusion. Client’s perception and interpretation of crisis event may differ noticeably from reality of situation. | Client plagued by intrusiveness of thoughts regarding crisis event. The appropriateness of client’s problem-solving and decision-making abilities likely adversely affected by obsessiveness, self-doubt, confusion. Client’s perception and interpretation of crisis event may differ substantially from reality of situation. | Gross inability to concentrate on anything except crisis event. Client so afflicted by obsessiveness, self-doubt, and confusion that problem-solving and decision-making abilities have “shut down.” Client’s perception and interpretation of crisis event may differ so substantially from reality of situation as to constitute threat to client’s welfare. |
Domain Severity Scale Summary
Affective _____ Cognitive _____ Behavioral _____ = Total _____
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