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 Name

Provider Number

Date of Service (dd/mm/yyyy)

County or Parish of Service

1st Employee #

2nd Employee #

Zip Code of Service

LOCATION OF SERVICE (select one)
temporary home (including home of friend or family, group homes, shelters,
apartments, trailers, and other dwellings)

school and child care (all ages through college)

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

community center (e.g., recreation club)

permanent home

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

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

workplace (workplace of the disaster survivor and/or first responder)
disaster recovery center (e.g., Federal Emergency Management Agency
[FEMA], American Red Cross)

phone counseling (outbound calls to participants lasting 15 minutes or longer)
hotline, helpline, or crisis line (inbound calls from participants lasting 15 minutes or longer)

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

medical center (e.g., doctor, dentist, hospital, mental health or substance use disorder

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

treatment office)
virtual (e.g., text line, online chat service, Zoom)

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 a supervisory staff member present during administration of this tool?

Yes

Fifth visit or later

No

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

illness, injury, or physical harm (self or household member)

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

life was threatened (self or household member)

past substance use/mental health problems

witnessed death/injury (self or household member)

home damaged or destroyed
vehicle or major property loss
other financial loss

assisted with rescue/recovery (self or household member)

past trauma

changed schools or learning format (e.g., virtual)

disaster-caused food insecurity

prolonged separation from social network/family,
physical isolation, or social distancing

disaster un- or underemployment
(self or household member)

preexisting physical disability

reduced or no access to reliable information/
communication
reduced or no access to reliable transportation

evacuated quickly with no time to prepare
displaced from home 1 week or more

DEMOGRAPHIC INFORMATION
Age (select one)

young adult (18–29 years)

adult (30–64 years)

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, developmental delay, etc.)
Mental health/substance use (psychiatric, substance use disorder, etc.)

older adult (65 years or older)

Gender (select one)

Male

Female

Transgender

Primary language spoken during this encounter (select one)

None of these

English

Spanish

Other

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

Asian

Black/African American

Native Hawaiian/Other Pacific Islander

White

Hispanic/Latino

Yes

Did you move from another country to the United States in the past 5 years? (select one)

No

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

QUESTIONS TO BE READ

5 = very much
RESPONDENT’S ANSWERS

1.

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

1

2

3

4

5

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

2

3

4

5

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

2

3

4

5

4.

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

1

2

3

4

5

5.

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

1

2

3

4

5

6.

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

1

2

3

4

5

7.

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

2

3

4

5

8.

How distressed or bothered are you about your reactions?

1

2

3

4

5

9.

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

1

2

3

4

5

10.

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

1

2

3

4

5

11.

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

1

2

3

4

5

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

In the past month, have you had thoughts about suicide?

No

Yes

13.

Have you ever made a suicide attempt?

No

Yes

14.

If yes to #12 or #13, Are you having thoughts of suicide right now?

No

Yes

1
1
1
1

REFERRAL INSTRUCTIONS
IF THE ANSWER TO ITEM #14 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 #14 IS “NO,” CONTINUE:
IF SCORE IS 3 OR HIGHER, OR IF THE ANSWER TO ITEMS #12 OR #13 IS “YES,” 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)
crisis counseling program services (e.g., group counseling, referral to teamleader,
follow-up visit)

community services (e.g., FEMA, loans, housing, employment, social services)
resources for those with disabilities or other access or functional needs

mental health services (e.g., professional, longer-term counseling, treatment,
behavioral, or psychiatric services)
substance use services (e.g., professional, behavioral, or medical treatment or
self-help groups, such as Alcoholics Anonymous or Narcotics Anonymous)

Did the participant accept one or more of the referral(s)?

other (specify in box)
Note the type of service for which you made the referral,
not the site to which you made the referral.
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
having an impact on 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., State-XXXX. PROVIDER NAME—The name of the program/agency.
PROVIDER #—The unique number under which your program/agency is providing services.
DATE OF SERVICE—The date of the encounter in the format mm/dd/yyyy, e.g., 01/01/2021.
COUNTY OR PARISH OF SERVICE—The county where the service occurred.
1st EMPLOYEE #—YOUR employee number issued by ODCES.
2nd EMPLOYEE #—Employee number issued by ODCES for your teammate during this encounter.
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 OR OTHER ACCESS OR FUNCTIONAL NEEDS—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/cognitive, or mental health/substance
use)? SELECT ALL THAT APPLY.
•

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

•

Intellectual/cognitive: includes a learning disability, birth defect, neurological disorder, developmental disability (e.g., Down
syndrome), and traumatic brain injury.

•

Mental health/substance use: includes psychiatric disorders, such as bipolar disorder, major depressive disorder, posttraumatic
stress disorder (PTSD), schizophrenia, and substance use disorders.

GENDER—The gender the person reports being. SELECT ONLY ONE.
PRIMARY LANGUAGE SPOKEN DURING THIS ENCOUNTER—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.
RACE/ETHNICITY—What race/ethnicity does the person identify as being? SELECT ALL THAT APPLY.
MOVED TO THE UNITED STATES IN THE PAST 5 YEARS—Indicate if any participant moved to the United States in the
past 5 years from any country and for any reason. SELECT ONLY ONE.
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. Each check mark counts as 1 point. 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.”
Thank you for taking the time to complete this form accurately and fully!
Paperwork Reduction Act Statement This information is being collected to assist the Substance Abuse and Mental Health Services Administration (SAMHSA)
with program monitoring of FEMA’s Crisis Counseling Assistance and Training Program. Crisis counselors are required to complete this form following the
delivery of crisis counseling services to disaster survivors (44 CFR 206.171 [F][3]). Information collected through this form will be used at an aggregate level to
determine the reach, consistency, and quality of the Crisis Counseling Assistance and Training Program. Under the Privacy Act of 1974, any personally
identifying information obtained will be kept private to the extent of the law. An agency may not conduct or sponsor, and a person is not required to respond to, a
collection of information unless it displays a currently valid Office of Management and Budget (OMB) control number. The OMB control number for this project is
0930-0270. Public reporting burden for this collection of information is estimated to average 15 minutes per assessment, including the time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send
comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to SAMHSA
Reports Clearance Officer, 5600 Fishers Lane, Room 15E57A, Rockville, MD 20857.