Form Adult Assessment a Adult Assessment a Adult Assessment and Referral Tool

Adult Assessment and Referral Tool

PROJECT #

OMB NO. 0930-0270
Expiration Date XX/XX/XXXX

The Crisis Counseling Assistance and Training Program (CCP) should have protocols or procedures in place for how a crisis counselor should respond if serious
reactions are indicated while using this tool. Many CCPs have team leaders or other staff with a mental health background to administer this tool to ensure proper
assessment and referral. All crisis counseling staff using this tool should have detailed training and guidance on use of the tool and when to make a referral for more
intensive services. Prior to use of this tool, the CCP should have identified at least one organization or agency that is willing to accept referrals from the CCP for more
intensive mental health or substance use intervention services.
Please use this tool as an interview guide
1) with adults who have received individual crisis counseling on two or more occasions before this visit (it is recommended on the third and fifth encounter) OR
2) with any adult at any time if you suspect the adult may be experiencing serious reactions to the disaster.
Provider Number

Provider Name
Date of Service (dd/mm/yyyy)

County of Service

st

nd

1 Employer #

2 Employer #

Zip Code of Service

LOCATION OF SERVICE (select one)
school and child care (all ages through college)

temporary home (including friend or family homes, group homes, shelters, apartments,
trailers, and other dwellings)

community center (e.g., recreation club)

IF A TEMPORARY HOME: PLEASE CHECK THIS BOX IF ANY CHILDREN
UNDER AGE 18 LIVE IN THIS HOME.

provider site/mental health agency (agency involved with the CCP)

permanent home

workplace (workplace of the disaster survivor and/or first responder

IF A PERMANENT HOME: PLEASE CHECK THIS BOX IF ANY CHILDREN
UNDER AGE 18 LIVE IN THIS HOME.

disaster recovery center (e.g., Federal Emergency Management Agency
[FEMA], American Red Cross)

phone counseling (15 minutes or longer)

place of worship (e.g., church, synagogue, mosque)

IF HOTLINE, HELPLINE, or CRISIS LINE, please check here.

retail (e.g., restaurant, mall, shopping center, store)

medical center (e.g., doctor, dentist, hospital, mental health specialty center)

public place/event (e.g., street, sidewalk, town square, fair, festival, sports)

other (specify in box)

VISIT NUMBER

First visit

Second visit

Third visit

Fourth visit

DURATION

15 - 29 minutes

30 – 44 minutes

45 – 59 minutes

60 minutes or more

Was the team lead or supervisory staff present during administration of this tool?

Yes

Fifth visit or later

No

RISK CATEGORIES (select all that apply)
family missing/dead

injured or physically harmed (self or household member)

evacuated quickly with no time to prepare

friend missing/dead

life was threatened (self or household member)

displaced from home 1 week or more

pet missing/dead

witnessed death/injury (self or household member)

sheltered in place or sought shelter due to immediate
threat of danger

home damaged or destroyed

assisted with rescue/recovery (self or household member)

past substance use/mental health problem

vehicle or major property loss

had to change schools

preexisting physical disability

other financial loss

prolonged separation from family

past trauma

disaster unemployed (self or household member)

DEMOGRAPHIC INFORMATION
Age (select one)

adult (18 - 39 years)

adult (40 - 64 years)

older adult (65 years or older)

Do you have a disability, or other access or functional need? If so, indicate the type (select all that apply).
Physical (mobility, visual, hearing, medical, etc.)
Intellectual/Cognitive (learning disability, mental retardation, etc.)
Mental Health/Substance Abuse (psychiatric, substance dependence, etc.)
Sex

Male

Female

Primary language spoken during this encounter (select one)
Ethnicity (select one)

Hispanic or Latino

English

Spanish

Other

Not Hispanic or Latino

Race (select all that apply)
American Indian/Alaska Native

Asian

Black or African American

Native Hawaiian/Pacific Islander

White

ASSESSMENT QUESTIONS
GIVE RESPONSE CARD TO RECIPIENT.
READ: These questions are about the reactions you have experienced IN THE PAST MONTH. By reactions, I mean feelings or emotions or thoughts
about the events. For each question choose one of the following responses from this card.

1 = not at all

2 = a little bit

3 = somewhat

4 = quite a bit

5 = very much
RESPONDENT’S ANSWERS

QUESTIONS TO BE READ
1.

How much have you been bothered by unwanted memories, nightmares, or reminders of what happened?

1

2.

How much effort have you made to avoid thinking or talking about what happened or doing things that remind
you of what happened?

1

3.

To what extent have you lost enjoyment in things, kept your distance from people, or found it difficult to
experience feelings because of what happened?

1

4.

How much have you been bothered by poor sleep, poor concentration, jumpiness, irritability, or feeling watchful
around you because of what happened?

1

How down or depressed have you been because of what happened?

1

5.

2
2
0

2
0

Has your ability to handle other stressful events or situations been harmed?

0

8.

Have your reactions interfered with how well you take care of your physical health? For example, are you eating
poorly, not getting enough rest, smoking more, or finding that you have increased your use of alcohol or other
substances?

1

How distressed or bothered are you about your reactions?

1

2
2

10.
11.

1

How much have your reactions affected your relationships with your family or friends or interfered with your
social, recreational, or community activities?

1

How concerned have you been about your ability to overcome problems you may face without further
assistance?

1

5

3

4

5

3

4

5

3

4

5

3

4

5

3

4

5

3

4

5

3

4

5

3

4

5

3

4

5

1

2
0

How much have your reactions interfered with your ability to work or carry out your daily activities, such as
housework or homework?

4

1

1

2
0

9.

3

1

0

7.

5

1

2

1

4

1

0

6.

3

1

2
0

1

2
0

1

2
0

1

0 no

1 yes

NUMBER OF RESPONSES OF 4 OR 5 (this is recipient's score)
12.

I also need to ask: Is there any possibility that you might hurt or kill yourself?

REFERRAL INSTRUCTIONS
IF THE ANSWER TO ITEM #12 IS “YES,” REFER FOR IMMEDIATE PSYCHIATRIC INTERVENTION. The CCP should have protocols or procedures in place for how a crisis counselor
should respond or react if the response is “YES.”
IF THE ANSWER TO ITEM #12 IS “NO,” CONTINUE:
IF SCORE IS 3 OR HIGHER, READ: FROM WHAT YOU HAVE TOLD ME, IT SEEMS THAT YOU MIGHT BENEFIT FROM PARTICIPATING IN ANOTHER SERVICE
[DESCRIBE]. I WOULD LIKE TO REFER YOU TO
.
IF SCORE IS BELOW 3, READ: FROM WHAT YOU HAVE TOLD ME, IT SEEMS THAT YOU ARE MANAGING YOUR REACTIONS. DOES THAT SEEM RIGHT TO YOU?
IF NO, READ: PERHAPS YOU WOULD BENEFIT FROM PARTICIPATING IN ANOTHER SERVICE
[DESCRIBE]. I WOULD LIKE TO REFER YOU TO

.

IF YES, READ: WE SHOULD DECIDE UPON SPECIFIC GOALS FOR COUNSELING THAT WE CAN MEET TODAY OR WITHIN ANOTHER COUPLE OF VISITS.

REFERRAL (select all that apply)
other crisis counseling program services (e.g., group counseling, referral to a team
leader, followup visit)

community services (e.g., FEMA, loans, housing, employment, social services)

tal health services (e.g., professional, longer-term counseling, treatment, behavioral,
or psychiatric services)

resources for those with disabilities, or other access or functional needs

substance abuse services (e.g., professional, behavioral, or medical treatment or selfhelp groups, such as Alcoholics Anonymous or Narcotics Anonymous)

other (specify in box)

Note the type of service for which you made the referral, not the site to which
you made the referral.
Did the participant accept one or more of the referral(s)?

no

yes

See “Referral Instructions” above.

INSTRUCTIONS:
ADULT ASSESSMENT AND REFERRAL TOOL
When to Use This Form:
It is recommended that this form be used with all adults who are intensive users of services. Intensive users are people who are participating in
their third individual crisis counseling visit with any crisis counselor from the program or who continue to suffer severe distress that may be
impacting their ability to perform routine daily activities. This form should be used as an interview guide (1) with adults receiving individual crisis
counseling on the third and fifth occasions OR (2) with any adult at any time if you suspect the adult may be experiencing serious reactions to the
disaster. Do not use this form with children; use the Child/Youth Assessment and Referral Tool.
PROJECT #--FEMA disaster declaration number, e.g., DR-XXXX-State. PROVIDER NAME--The name of the program/agency.
PROVIDER #--The unique number under which your program/agency is providing services.
1st EMPLOYEE #--YOUR employee number.

2nd EMPLOYEE #--Employee number of your teammate during this encounter.

DATE OF SERVICE--The date of the encounter in the format mm/dd/yyyy, e.g., 01/01/2012.
COUNTY OF SERVICE--The county where the service occurred. ZIP CODE OF SERVICE--The ZIP code where the service occurred.
LOCATION OF SERVICE--Where did the encounter occur? SELECT ONLY ONE.
VISIT NUMBER--Is this the first, second, third, fourth, or fifth or later visit for this person to your program? All visits did not have to be with you.
SELECT ONLY ONE.
DURATION--How long did your encounter last? SELECT ONLY ONE. If the encounter was under 15 minutes, record it on the Weekly Tally Sheet.
RISK CATEGORIES--These are factors that an individual may have experienced or may have present in his or her life that could increase his or
her need for services. MORE THAN ONE CATEGORY MAY APPLY. SELECT ALL CATEGORIES THAT APPLY. The Adult Assessment and
Referral Tool is an interview guide, and you may ask the individual whether or not he or she has experienced the listed factors. (Note that this
instruction is not the same as for the Individual/Family Crisis Counseling Services Encounter Log.)
DEMOGRAPHIC INFORMATION--For each variable, SELECT ONLY ONE. The Adult Assessment and Referral Tool is an interview guide, and you
may ask the individual these questions as needed. (Note that this instruction is not the same as for the Individual/Family Crisis Counseling Services
Encounter Log.) For each question, read the options, and ask the individual to select the option or options that best describe(s) him or her.
AGE--What age does the person indicate he or she is? SELECT ONLY ONE.
PERSONS WITH DISABILITIES--If the participant considers him- or herself to have a disability or access or functional need, what type
does he or she indicate (physical, Intellectual, or mental health/substance abuse)? SELECT ALL THAT APPLY.
•

Physical: Includes disorders that impair mobility, seeing, and hearing, as well as medical conditions, such as diabetes, lupus,
Parkinson's, AIDS, multiple sclerosis (MS).

•

Intellectual/Cognitive: Includes a learning disability, birth defect, neurological disorder, developmental disability, or traumatic brain
injury, e.g., Down syndrome and mental retardation.

•

Mental Health/Substance Use: Includes psychiatric disorders, such as bipolar disorder, depression, posttraumatic stress disorder
(PTSD), schizophrenia, and substance dependence.

SEX--The sex the person reports to be. SELECT ONLY ONE.
PRIMARY LANGUAGE SPOKEN DURING ENCOUNTER(S)--Which language did you actually and primarily use to speak with this
individual during the encounter? This may be different from the preferred language. If “OTHER” (not English or Spanish), fill in the other
language that the person used (this may include sign language). SELECT ONLY ONE.
ETHNICITY--Does this person self-identify as Hispanic/Latino? SELECT ONLY ONE.
RACE--What race does the person identify as being? SELECT ALL THAT APPLY.
ASSESSMENT QUESTIONS--GIVE THE RESPONSE CARD TO THE INDIVIDUAL.
For each question, put a check mark in the appropriate box based on the individual's responses.
At the end of the 11 questions, COUNT the number of check marks in boxes 4 and 5. This is the person's score.
For example, an individual who answered “quite a bit” on Questions 6 and 7 and “very much” on Question 11 and “somewhat” on
Questions 1-5 and 8-10 would receive a score of 3.
REFERRALS--In the REFERRAL box, select all of the types of services to which you referred the person. If the service is not listed, please
provide the type of service next to "other.”
Please submit the completed form to the designated person in your agency who will review the form.
Thank you for taking the time to complete this form accurately and fully!
Public Burden Statement: