SCCS Consumer Triage Form w/ Columbia

Consumer Triage Form

South Central Crisis Service
Call Type:

Crisis CallMobile48 Hour Follow-UpCrisis Appointment
Time of Appointment:*

:HourMinutesAM/PM Option
On-Call Clinician:*

First NameLast Name
Date:*

MonthDayYear
Date
Time Call Began:*

:HourMinutesAM/PM Option
Client Name:*

First NameLast Name
Age of Client:*
If unknown, enter "00."
Date of Birth:*

MonthDayYear
If unknown, enter "01-01-1000."
Gender:*

MaleFemaleOther
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number:*
Agency:*
Therapist:*

First NameLast Name
Psychiatrist:*

First NameLast Name
Provider Phone Number:*
Emergency Contact:*

First NameLast Name
Emergency Contact Phone Number:*
Relationship to Client:*

SpouseParentOther
History of Present Illness
1) Why did you call the crisis service today?*
2) Is it constant, acute, chronic, improved, or worsening?*
3) Have you had this issue before? When? And for how long?*
4) Are there immediate threats to your safety, well-being or sobriety?*

YesNoN/A
If Yes, please describe:*
5) Are you currently able to take care of yourself and perform basic activities of daily living?*

YesNoN/A
If No, please describe:*
6) What efforts have you made to improve the problem?*
7) Do you have minor children?*

YesNoN/A
If Yes, are they safe and being cared for?*

YesNoN/A
If No, specify the care plan:*
8) Have you ever had any thoughts of seriously harming or killing anyone else?*

YesNoN/A
a) Have you hurt others in the past?*

YesNoN/A
If Yes, please specify:*
b) Do you have any intention of following through on these thoughts to harm others and/or have you made any plans to do so?*

YesNoN/A
If Yes, please specify:*
c) What stops you from following through on those plans?*
d) Do you have any weapons?*

YesNoN/A
If Yes, please specify:*
9) Are you hearing or seeing things others are not?*

YesNoN/A
If Yes, please specify:*
Medical History
1) Which psychiatric medications are you currently taking?*
2) Are you taking the medication as prescribed?*

YesNoN/A
3) Describe any current, severe medical problems?*
4) Are you receiving any treatment for these problems?*

YesNoN/A
5) Do you think think these problems are affecting you now?*

YesNoN/A
If Yes, please specify:*
Substance Use History
1) Which substances have you used this week? Today?*
2) How much of these substances do you use? How often?*
3) Do you have a history of serious, life-threatening withdrawal?*

YesNoN/A
If Yes, please specify:*
4) Are you currently having similar withdrawal symptoms?*

YesNoN/A
5) Do you give verbal consent for SCCS to disclose your protected behavioral health information in this documentation to your community provider?*

YesNoN/A - alcohol or substance abuse information is indicated and cannot be shared
Social History
1) Are there persons in your life who are supportive?*

YesNoN/A
If yes, who are they?*
2) Do you have any thoughts about what would be most helpful to you right now?*
Mental Status
1) Mood:*

EuthymicEuphoricDysphoricAnxiousOther
2) Attitude:*

CooperativeGuardedSuspiciousUncooperativeOther
3) Speech:*

NormalDelayedSoftLoudPressuredPerseverativeSlurredOther
4) Thought Process:*

IntactCircumstantialLOATangentialFlight of IdeasOther
5) Thought Content:*

LogicalIdeas of ReferenceDelusionsParanoid IdeationObsessionsPoverty of ContentCompulsionsPhobiasOther
6) Disturbances of Perception:*

Not PresentPresentVisual HallucinationsAuditory HalluciantionsOther
Key Evaluation Components/ Formulation: *
Disposition: *
Has a crisis appointment been scheduled?*

YesNo
If yes, what time is the appointment?

:HourMinutesAM/PM Option
Was there a problem with the case?*

YesNo
If yes, please explain:*
Alert sheet referenced (Only if present):*

YesNoN/A
Disclosures:*

DCFPolice DepartmentNoneOther
Name of the Disclosure Party:*

First NameLast Name
Was there a consultation regarding this case?*

YesNo
Name of consultation party:
Time Call Ended:*

:HourMinutesAM/PM Option
Total Time:
Total Minutes
Type of Call*

RoutineUrgent
Columbia Suicide Severity Rating Scale

Screening Version - Recent
Columbia Suicide Severity Rating Scale:

Performed - Refer to clinical formulationNot performed
If not preformed why?

Client RefusalCall DisconnectedUnable to assessOther
Ask questions that are bold and underlined.

Ask Questions 1 & 2.

1) Wish to be Dead:

Person endorses thoughts about a wish to be dead or not alive anymore, or wish to fall asleep and not wake up.
In the past month, have you wished you were dead or wished you could go to sleep and not wake up?*

YesNo
2) Suicidal Thoughts

General non-specific thoughts of wanting to end one's life/die by suicide, "I've thought about killing myself" without general thoughts of ways to kill onself/associated methods, intent, or plan.
In the past month, have you actually had any thoughts of killing yourself?*

YesNo
If YES, to question 2, ask questions 3, 4, 5, and 6. If NO, to questions 2, go directly to question 6.
3) Suicidal Thoughts with Method (Without Specific Plan or Intent to Act):

Person endorses thoughts of suicide and has thought of at least one method during the assessment period. This is different than a specific plan with time, place, or method details worked out. "I thought about taking an overdose, but I never made a specific plan as to when where, or how I would actually do it...and I would never go through with it."
In the past month, have you been thinking about how you might kill yourself?

YesNo
4) Suicidal Intent (Without Specific Plan):

Active suicidal thoughts of killing oneself and patient reports having some intent to act on such thoughts, as opposed to "I have the thoughts, but I definitely will not do anything about them."
In the past month, have you had these thoughts and had some intention of acting on them?

YesNo
5) Suicide Intent with Specific Plan:

Thoughts of killing oneself with details of plan fully or partially worked out and person has some intent to carry it out.
In the past month, have you started to work out or worked out the details of how to kill yourself, and do you intend to carry out this plan?

YesNo
6) Suicide Behavior
In the past three months, have you done anything, started to do anything, or prepared to do anything to end your life? Examples: Collected pills, obtained a gun, gave away valuables, wrote a will or suicide note, took out pills but didn't swallow any, held a gun but changed your mind or it was grabbed from your hand, went to the roof but didn't jump; or actually took pills, tried to shoot yourself, cut yourself, tried to hang yourself, etc.*

YesNo
Action Taken*

No findingsConsulted SupervisorMobile DispatchedCalled 911
Clinician Signature:*

Clear
Agency receiving form:*
Should be Empty:

Consumer Triage Form

History of Present Illness

Medical History

Substance Use History

Social History

Mental Status

Columbia Suicide Severity Rating Scale