MENTAL HEALTH TRIAGE RATING SCALE - AHVNA



MENTAL HEALTH TRIAGE RATING SCALE

INSTRUCTIONS: Score 1 to 5 in each category on the right using the descriptive standards and guidelines.

|PATIENT INFORMATION DATE: ______________ |A. DANGEROUS (Circle Number) |

| | |

|Name: DOB |Expresses or hallucinates (hears commands) suicidal/homicidal ideas or has made attempt in present illness. |

| |Unpredictably impulsive / violent. |

|PHN#: Circle Male/Female |Expresses suicidal ideation but behaviour is somewhat dependent on the stress in the environment. History of violent|

| |or impulsive behaviour but no current signs. |

|Postal Code: Phone #: _______ |Some suicidal / homicidal ideas with ambivalence or has made ineffective gestures. Questionable impulse control. |

| |Some suicidal / homicidal ideation or behaviour, or history of same, but clearly wishes and is able to control |

|FACILITY/ AGENCY _________________________ |behaviour. |

| |5. No suicidal / homicidal ideation or behaviour. No history of violence / impulsive behaviour. |

|OUTCOME: |B. SUPPORT SYSTEM (Circle Number) |

|Certified: □ Location: _________________________ | |

| |No family, friends or others. Agencies cannot provide immediate support needed. |

|Voluntary Admission: □ Location: ______________________________ |Some support might be mobilized but its effectiveness will be limited. |

| |Support system potentially available but significant difficulties exist mobilizing it. |

|Admit to Aspen |Interested family, friends, or others but some question exists of ability or willingness to help. |

|Health Centre □ Location: ________________________________ |5. Interested family, friends or others able and willing to provide support needs. |

| | |

|Released □ To Where___ Phone _________ | |

|With Whom _____________________ | |

| |C. ABILITY TO COOPERATE (Circle Number) |

|Consulted With | |

| |Unable to cooperate or actively refuses. |

|Agreement to |Shows little interest in or comprehension of efforts to be made in his behalf. |

|Follow Up: Yes □ No □ If No, Reason for Refusal: |Passively accepts intervention maneuvers. |

|_____________________________________________________ |Wants to get help but is ambivalent or motivation is not strong. |

| |Actively seeks outpatient treatment. Willing and able to cooperate. |

|Follow-up referrals made to: | |

|Mental Health Clinic □ AADAC □ Home Care □ | |

|Association for |Did the patient agree to sharing information with Aspen Regional Health Services? |

|Community Living □ Physician □ Public Health □ |Yes □ No □ Signature: _________________________________ |

|Other □ |(Signature required if referral by Community Agency other than Aspen RHA) |

|____________________________________________________ | |

|Information/Brochure Provided: Yes □ No □ |Please fax this scale to your local Mental Health Clinic |

| | |

|Signature of Nurse / Physician |Westlock: 349-5846 Barrhead: 674-8352 |

| |Mayerthorpe: 786-2023 Swan Hills: 333-7009 |

| |Onoway: 967-9117 |

|TOTAL SCORE (A +B+C) = ________ |3 – 9 = High Intensity Crisis |10 – 12 = Medium Intensity Crisis |13 – 15 = Low End Crisis |

This tool is currently being used in Region 7. Feel free to adapt the form with your own local Mental Health Clinic information.

Dr Bengelsdorf worked with doctors to create a tool to assess risk. This tool is useful in assessing how safe the individual is by determining their responses to three questions that focus on

➢ dangerousness

➢ support system

➢ ability to cooperate

To assess determine the responses to the questions and calculate the score

➢ If High Intensity Crisis (score 3-9) then the individual would need to be hospitalized

➢ If Medium Intensity Crisis (score 10-12) then the individual needs to see someone this week.

➢ If Low End Crisis (score 13-15) then the individual should set up an appointment

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