Triage Assessment Form

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:
Alexa, a 17-year-old Hispanic female, ran away from home. The police returned her to her
home, but within a week Alexa had attempted suicide by taking her father's prescription
medication for high blood pressure. Alexa had been showing signs of depression and was seen
for mental health counseling a year previously for eight sessions. After receiving counseling,
Alexa withdrew and stated that she felt unuseful at home and unwelcome at school. Feelings of
worthlessness and anger arose periodically when her parents tried to engage her about school
events. Alexa had several close friends and one young man she called her "beau," though she
claimed there was no serious intimacy between them. She refused to return to counseling
sessions, saying that the time was better spent talking with her friends. She complained that her

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parents were too strict with curfew times and asked too many questions. In the past week,

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Alexa was discovered to have skipped two days of school and refused to tell her parents where

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she had been. Alexa's mother found a bottle of pills and a bottle of vodka in her room.

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Affective Domain

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Identify and describe briefly the affect that is present. (If more than one affect is experienced,
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rate with number 1 being primary, number 2 secondary, number 3 tertiary.)
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Anger/Hostility
Anger is the secondary domain. Alexa struggles to control her anger. She reports feeling
angry throughout the day. She displays anger towards her parents when thy attempt to talk to
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her. She will not admit that her anger is getting out of control.
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Anxiety/Fear
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There are not any signs of anxiety or fear.

Sadness/Melancholy
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Alexa is severely depressed. There is a dramatic change in her interests in life and others.
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Affective Severity Scale

Highlight the number that most closely corresponds with client’s reaction to crisis.
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1 2 3 4 5 6 7 8 9 10
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No Minimal Low Moderate Marked Severe

Impairment Impairment Impairment Impairment Impairment Impairment

Stable mood Affect Affect Affect may be Negative affect Decompensation

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with normal appropriate appropriate to incongruent experienced at or

variation of to situation. situation but with situation. markedly higher depersonalization
affect Brief periods increasingly Extended level than evident.
appropriate during which longer periods periods of situation
to daily negative during which intense warrants. Affects

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functioning. mood is negative mood negative may be obviously

experienced is experienced moods. Mood incongruent with
slightly more slightly more is experienced situation. Mood
intensely intensely than noticeably swings, if
than situation more intensely occurring, are
situation warrants. than situation pronounced.
warrants. Client warrants. Onset of negative
Emotions perceives Liability of moods are
are emotions as affect may be perceived by
substantially being present. Effort client as not
under client substantially required to being under
control. under control. control volitional control.
emotions.

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

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Alexa does not display behaviors or thought processes that would indicate that she is open to

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addressing her current problems. Alexa reports that her thoughts and behaviors are under

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control to some extent and does not understand how her thoughts and behaviors have a
negative impact on her social relationships.

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Alexa is not willing to open up with the counselor regarding her problems. There’s an obvious
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uneasiness when the topic of depression and alcohol use is mentioned. She appears to
believe that there is nothing wrong with her behavior and thoughts. The counselor will apply
Cognitive Behavioral Therapy with a depression component with the client.
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Avoidance
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Primary (1): Alexa shows an avoidance behavioral approach. She is using alcohol and pills as
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an attempt to cope with her problems. She also reports that she tried to commit suicide to
escape dealing with her situation.
Avoidance is the primary domain. Alexa is displaying avoidance by alcohol use and
unprescribed pills as a comping mechanism. She has also attempted suicide.
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Immobility
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Immobility is the secondary domain. Alexa is experiencing immobility as a result of her

feelings as not feeling welcome at school and unuseful at home. She has chosen to avoid
everyone because she does not know how to deal with her issues.
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Behavioral Severity Scale

Highlight the number that most closely corresponds with client’s reaction to crisis.
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1 2 3 4 5 6 7 8 9 10

No Minimal Low Moderate Marked Severe

Impairment Impairment Impairment Impairment Impairment Impairment

Coping Occasional Occasional Client displays Client Behavior is

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 Triage Assessment Form

behavior use of use of coping displays erratic,

appropriate to ineffective ineffective behaviors that coping unpredictable.
crisis event. coping coping may be behaviors that Client’s
Client behaviors. behaviors. ineffective and are likely to behaviors are
performs Client Client neglects maladaptive. exacerbate harmful to self
those tasks performs those some tasks Ability to crisis and/or others.
necessary for tasks necessary for perform tasks situation.
daily necessary for daily necessary for Ability to
functioning. daily functioning. daily perform tasks
functioning but functioning is necessary for
does so with noticeably daily
noticeable compromised. functioning is
effort. markedly
absent.

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

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primary, number 2 secondary, number 3 tertiary.)

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PHYSICAL (food, water, safety, shelter, et cetera):

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Transgression _____ Threat ___X__ Loss _____
Alexa has not given up on fulfilling her basic needs (food, water, safety). She lives with her

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parents, so she has access to food, water and safety. Alexa recently attempted to run away
from home; therefore, her a risk has been placed on her safety and basic needs.
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PSYCHOLOGICAL (self-concept, emotional well-being, identity):
Transgression _____ Threat _____ Loss __X___
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Alexa is dealing with a lot of issues. She could possibly be struggling with a lack of self-
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esteem. She reports feeling unuseful and unwelcome from her family and friends.
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SOCIAL RELATIONSHIPS (family, friends, coworkers, et cetera):

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Transgression _____ Threat __X___ Loss _____

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Alexa has experienced isolation, social withdrawal from social group and peers, conflict and
emotional disconnection from her parents and family.
MORAL/SPIRITUAL (personal integrity, values, beliefs):
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Transgression _____ Threat _____ Loss ___X__

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There is a lack of information that reveals Alexa’s current spiritual state. As previously
mentioned, Alexa does not have a desire to attend school so its very likely that there is a lack
of interest in attending church services.
Cognitive Severity Scale
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Highlight the number that most closely corresponds with client’s reaction to crisis.
1 2 3 4 5 6 7 8 9 10

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 Triage Assessment Form

No Minimal Low Moderate Marked Severe

Impairment Impairment Impairment Impairment Impairment Impairment

Concentration Client’s Occasional Frequent Client plagued Gross inability

intact. Client thoughts disturbance of disturbance of by intrusiveness to concentrate
displays may drift to concentration. concentration. of thoughts on anything
normal crisis event Client Intrusive regarding crisis except crisis
problem- but focus of perceives thoughts of event. The event. Client so
solving and thoughts is diminished crisis event appropriateness afflicted by
decision- under control over with limited of client’s obsessiveness,
making volitional thoughts of control. problem-solving self-doubt, and
abilities. control. crisis event. Problem- and decision- confusion that
Client’s Problem- Client solving and making abilities problem-solving
perception solving and experiences decision- likely adversely and decision-
and decision- recurrent making abilities affected by making abilities
interpretation making difficulties with adversely obsessiveness, have “shut
of crisis event abilities problem- affected by self-doubt, down.” Client’s
match reality minimally solving and obsessiveness, confusion. perception and
of situation. affected. decision- self-doubt, Client’s interpretation of

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Client’s making confusion. perception and crisis event

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perception abilities. Client’s interpretation of may differ so
and Client’s perception and crisis event may substantially

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interpretation perception and interpretation of differ from reality of
of crisis interpretation of crisis event substantially situation as to

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event crisis event may differ from reality of constitute

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substantially may differ in noticeably from situation. threat to client’s
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match reality some respects reality of welfare.
of situation. from reality of situation.
situation.
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Domain Severity Scale Summary

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Affective ___8__ Cognitive __7___ Behavioral ___7__ = Total ___22__

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