Attachment 4 - Survey: Adult Assessment Referal Tool - 1/6/09

Project

OMB NO. 0930-0270
Expiration Date xx/xx/xxxx

Adult Assessment & Referral Tool
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
OR
(2) with any adult at any time if you suspect the adult may be experiencing serious reactions to the disaster.
Provider Name

Provider #

Date of Service (mm/dd/yyyy)

Employee #

County Code of Service

Zip Code of Service

CHARACTERISTICS of ENCOUNTER
LOCATION of SERVICE (select one)
school & child care (all ages through college)
community center (e.g., government, recreation, social services)

home (temporary or permanent; including friend or family homes; group
homes; including houses, apartments, trailers, and other dwellings)
IF HOME: PLEASE CHECK THIS BOX IF ANY
CHILDREN < AGE 18 LIVE IN THIS HOME.

provider site (agency involved with CCP)
workplace (e.g., office workers, public safety)

phone counseling (15 minutes or longer, including "hot-lines" & "life-lines")

disaster recovery center (e.g., FEMA, Red Cross)

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

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

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

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

other (specify in box) >

T
e

VISIT NUMBER

1st visit

2nd visit

3rd visit

4th visit

DURATION

15-29 minutes

30-44 minutes

45-59 minutes

60 minutes or more

5th visit or more

RISK CATEGORIES (select all that apply)
family member missing or dead

injured or physically harmed (self or household)

evacuated quickly with no time to prepare

friend missing or dead

life was threatened (self or household)

prolonged separation from family

pet missing or dead

witnessed death/injury (self or household)

displaced from home 1 week or more

home damaged or destroyed

assisted with rescue/recovery (self or household)

past substance use/mental health problem

vehicle or major property loss

disaster unemployed (self or household)

pre-existing physical disability

other financial loss

past trauma

DEMOGRAPHIC INFORMATION
Age (select one)

Sex (select one)

Race (select one or more)

Ethnicity (select one)

adult (18-39)

male

American Indian / Alaska Native

Hispanic or Latino

adult (40-64)

female

Asian

not Hispanic or Latino

adult (65+)

Black or African American

Primary Language of Contact (select one)

Native Hawaiian / Pacific Islander

English

White

Spanish
other (specify in box)>

PLEASE CONTINUE ON PAGE 2 (ON BACK)

Adult Assessment & Referral Tool page 2: 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 ANSWER

QUESTIONS TO BE READ
1

2

3

4

5

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

1.

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

2.

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?

no

yes

REFERRAL INSTRUCTIONS
IF THE ANSWER TO ITEM #12 IS "YES," REFER FOR IMMEDIATE PSYCHIATRIC INTERVENTION.
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 were communicated)
other crisis counseling program services (e.g., group counseling,
team leader, follow-up)

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

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

other (specify in box)>

substance abuse services (e.g., professional, behavioral, or
medical treatment or self-help groups, such as AA or NA)
Did the participant accept one or more of the referral(s)?

Note what the referral was for not where it was made to.

no

yes

INSTRUCTIONS:
ADULT ASSESSMENT & REFERRAL TOOL
When to Use This Form:
This form is used as an interview guide (1) with adults who have received individual crisis counseling on two or more occasions before this
visit 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 Assessment & Referral Tool.
PROVIDER NAME - The name of the program/agency.
PROVIDER # - The unique number your program/agency is providing services under.
EMPLOYEE # - YOUR employee number.
DATE OF SERVICE - The date of the encounter in the format MM/DD/YYYY, e.g., 01/01/2008.
COUNTY CODE OF SERVICE - The 3 digit FIPS code for the county where the service occurred.
ZIP CODE OF SERVICE - The zip code of the location where the service occurred.
LOCATION OF SERVICE - Where did you provide the service? SELECT ONLY ONE.
VISIT NUMBER - Based on your conversation with the individual, is this the 1st, 2nd, 3rd, 4th, 5th or more 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 < 15 minutes, record it on the Weekly Tally.
RISK CATEGORIES - These are factors that an individual may have experienced or may have present in their life that could increase their
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 this instruction is not the same as for the Individual 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 ask the individual these questions, as needed. (Note this instruction is not the same as for the
Individual Crisis Counseling Services Encounter Log.) For each question, read the options, and ask the individual to
select the option or options that best describes him or her.
AGE - SELECT ONLY ONE.
SEX - SELECT ONLY ONE
RACE - SELECT ALL THAT APPLY.
ETHNICITY - SELECT ONLY ONE.
PRIMARY LANGUAGE OF CONTACT - What language did you actually and primarily use to speak with this individual during
the encounter? This may be different than the preferred language. If “OTHER” (not English or Spanish), fill in the other
language. 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. 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.
The assessment questions come from the Sprint-E © and are used with permission. See the Evaluation Manual for documentation
of reliability and validity.
REFERRALS - In the REFERRAL box, select all of the types of services you referred the person to. If the service is not listed,
please provide the type of service next to “OTHER SERVICES.”

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 completely!

Public Burden Statement: 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 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 20 minutes per encounter per year, 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, 1 Choke Cherry Road, Room 7-1044, Rockville, Maryland,
20857.