Triage/Low Demand Shelter Screening Form
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- Gervase Riley
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1 Triage/Low Demand Shelter Screening Form Arrest History Date: Charge Type: Charge: Arrest Date: Was client Convicted? Conviction Date: City: State: County: SPN/Jacket # (Can be found on the Client s statement of problem/needs: Presenting Problem Collateral statement of problems/needs: Referral source and purpose of referral (include precipitating factors): List current resources: Current Resources Current Risk Assessment Risk of Suicide Yes or No Are you currently having thoughts of harming yourself? Do you feel hopeless about your current life situation? Have you attempted suicide in the past 30 days? Risk of Violence Yes or No Do you have thoughts of harming another person?
2 Have you ever been arrested for a crime involving violence? Have you pushed, grabbed, slapped, choked, or kicked another person in the past two years? Domestic Violence/Abuse/Neglect/Exploitation/Trauma Yes or No Have you ever been emotionally or physically abused by your partner or someone important to you? (Yes or No) Within the last year, have you been hit, slapped, kicked or otherwise physically hurt by someone? (Yes or No) If yes, by whom? Total number of times: If yes, by whom? Total number of times: Are you afraid of your partner or anyone else you listed above? Other risks (To self or other) Abuse Neglect Exploitation Other Describe: If current risks are identified (by one or more answers of Yes), what action will be taken or explain why action isn t necessary. Based on clinical findings, client s needs are: None Mild Moderate Severe Very Severe Suicide Risk Assessment Does client have any of the following: Yes or No Method: Means: Time & Place: Prior Attempts: Describe number, method and severity of prior attempts: Is client affected by or have any of the following: Yes or No Substance Abuse: Physical illness or pain: Loss: Hopelessness: Plans for the Future: Willingness to Use Supports: Impulsivity: Connection with Others:
3 Violence Risk Assessment Answer the following question: Yes or No Plans to Commit Violence: Client has a history of Violence (person, property, animals): Substance Abuser: Has Potential Triggers: Describe potential or current life events/social circumstances that may trigger violence: Hostility: Impulsivity: Thought Disorder: Presence of Antisocial Behaviors: Social Contact: Attitude toward interviewer/interview situation: Signs / Symptoms Cognitive Impaired short term memory Impaired long term memory Idea of hopelessness Excessive guilt Ideas of worthlessness: Other(describe): Answer questions: Good / Fair / Poor / NA Judgment: Insight: Thought Auditory Hallucinations Visual Hallucinations Olfactory Hallucinations Tactile Hallucinations Delusions Paranoia Tangential Circumstantial Bizarre Coherent Grandiose Racing Blocked Somatic complaints Obessive/compulsive Logical & Goal directed Phobias Other (describe) Risk of Suicide: (Yes or No)
4 Risk of Homicide: (Yes or No) Mood/Affect Depressed Elevated Expansive Flat Constricted Anxious Labile Angry Inappropriate Despairing Appropriate Euthymic Other (describe) Sensorium Delirium / Clouding of Consciousness Stupor Lethargic Disoriented: Self Person Place Time Situation Oriented in all spheres Other: (describe) Speech Pressured Impoverished Slow paced Rapid Slurred Hyperverbal Normal Other: (describe) Psychomotor Agitated Restlessness Pacing Retardation Tremors Rigidity Normal Other: (describe) Check all current problem areas: Problem Checklist Including Functional Domain Anger/Rage Oppositional Behaviors Inattention Impulsivity Bereavement Issues Traumatic Stress (Have you ever experienced a life threatening event?) Family/Interpersonal Relationships Pertinent Health or Pain Issues Work/School Socio/Legal ADL Functioning Psychosocial Stressors Explain all checked responses:
5 In the past year, have you ever used alcohol or drugs more than you meant to? Have you felt you wanted or needed to cut down on your drinking or drug use in the past year: Other addictive behaviors: Gambling Sexual Nicotine Caffeine Spending Shoplifing Pertinent Family History: (to include mental health and alcohol/drug history) Treatment History Longest Period of Abstinence from mood altering drugs: From: To History of 12-Step/Community Sobriety Group Attendance: From: To (Yes or No) Currently Court-Ordered? Describe including dates: (Yes or No) Previously Court-Ordered? Describe including dates: Co-Occuring Mental Illness and Substance Abuse Disorders Previous diagnosis of mental illness If yes, describe Current mental health symptoms appear to be substance induced If yes, describe Age client had first psychiatric symptoms Age client began using substances Comments
6 Are there psychiatric symptoms in the absence of substance abuse? (Yes or No) If yes, describe Level of Substance Abuse Impairment (as evidenced by DSM IV None criteria) Circle one leave blank for none Mild Severe Moderate Very Severe Comments (treatment recommendations and summary to be included in integrated summary) Hospitalization / Psychiatric Treatment Problem Date: Problem: Treatment: Clinic/Hospital/Doctor: Treatment Location: Medication: Drug use History Substance Abuse Drug of Choice: Physiological Effects of Use History of Symptoms of Intoxication None Reported Blackouts Bumps, Bruises Chest or Heart Pain Confusion Distended Abdomen High Blood Pressure Liver Problems Loss of Appetite Vision Problems Red Face/Nose Slurred Speech Swelling Weight Loss Hallucinations Paranoia Other History of Withdrawal Symptoms None Reported AM Alcohol/Drug Use Agitation Anxiety DT s Depression Hallucinations High Blood Pressure Suicidality Insomnia Shakes Nausea Violence Excessive Sweating Shortness of Breath Seizures Fatigue Other Positive Consequences of Substance Use None Identified Improved Socialization Coping/Relief from Psychiatric Symptoms Facilitation of Intimacy/Sex Pleasure Feels more normal or productive
7 Reduces Boredom/something to do Reduction of craving or withdrawal symptoms Other History of Significant Incidents Related to Alcohol/Drugs None Identified Family Problems Work Problems Legal Problems DUI Money Problems Health Problems Car Accidents Increased Psychiatric Symptoms Housing Problems Physical Abuse/Domestic Violence Decreased/Cessation of Treatment Participation Sexual Trauma/Abuse Other Attitude toward Interviewer/Interview situation: History of Use Substance: Frequency of Use: Amount of Use: Age of First Use: Date Last Used: Amount Last Used: Diagnostic Review Diagnostic Axes I-IV Axis I: Clinical disorders and other conditions that may be a focus of clinical attention Summarize symptoms, precipitating factor, onset, duration and intensity that support an Axis I Diagnosis Axis I ID: Axis I Description: Axis II: Personality disorders and mental retardation Describe significant personality characteristics that reach a level of clinical significance and support an Axis II diagnosis. List supporting evidence for a mental retardation diagnosis, including general intellectual functioning and adaptive functioning. Axis II ID: Axis II description: Active Diagnosis Mental Health Substance Abuse Co-Occurring No Diagnosis Axis III: General Medical Conditions Summarize relevant medical issues as they pertain to the presenting problems
8 Summarize the client s psychosocial and environmental problems that may affect the diagnosis, treatment, and prognosis: Axis IV: Psychosocial and Environmental Problems Axis IV ID: Axis IV description: Primary Axis: Axis IV: Psychosocial and Environmental Problems GAF: Diagnostic Impressions/conclusions Treatment & Therapeutic Education Client s Learning Preference Reading Video Audio Lecture Alone Lecture Alone Group Other/Describe: History of Learning Difficulties Other: None Mental Retardation Special School Placement Dyslexia Other Learning Disability Learning/Treatment Considerations Inability to Read or None Write Language Hearing Impairment Visual Impairment Cultural/Religious Domestic Violence Abuse/Neglect/Exploitation Accessibility/Transportation Physical Disability Primary Language Other:
9 Special Communication Needs Other: None TDD/TTY Device Sign Language Interpreter Language Interpreter Service-Other Spoken Language Recommended Topics for Client/Family Education Medication Diagnosis-Specific Basic Living Skills Parenting Alcohol/Drug Smoking/Tobacco HIV/HBV Health Nutrition Community Resources Other:
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