Triage Form
Your answer
Client Initial and Reference No ( Both Required) *
Your answer
Client DOB *
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DD
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YYYY
Client's Home Address *
Your answer
Client's Telephone Number *
Your answer
Consent for voicemails *
GP Address (Please note that the response to this questions is necessary for the client to proceed with counselling. If the client declines, please complete the triage in full and refer to your Case Manager before booking the clients first session) *
Your answer
Are you currently signed off work? *
Emergency Contact Name *
Your answer
Relationship to Client
Your answer
Emergency contact telephone number *
Your answer
Summary of difficulties Please give sufficient detail of the client's area of difficulty, how it is currently impacting them and details of any precipitating or protective factors.
Your answer
Any past mental health issues?
Your answer
Any past or ongoing counselling?
Your answer
What are the clients goals for counselling?
Your answer
Core 10: Please answer these questions based on the last week
Not at all
Only Occasionally
Sometimes
Often
Most or all of the time
I have felt tense anxious or nervous
I have felt I someone to turn to for support when needed
I have felt able to cope when things go wrong
Talking to people has felt too much for me
I have panic or terror
I have made plans to end my life
I have had difficulty getting to sleep or staying asleep
I have felt despairing or hopeless
I have felt unhappy
Unwanted images or memories have been distressing me
SCORING THE CORE: PLEASE CROSS REFERENCE THE ANSWERS YOUR CLIENT HAS GIVEN ABOVE WITH THE SCORING FORMAT AS SHOWN BELOW TO GET A TOTAL CORE SCORE ( i.e if your client answered "sometimes" to question 1, their score on that question would be 2).
Total Core 10 Score;
Your answer
The scores for each CORE question are displayed below;
Please use this risk guide to support the risk assessment
1) Have you ever had thoughts about wanting to harm yourself or done things to harm your wellbeing? *
Comments; Please include precipitating and protective factors
Your answer
Overall self harm risk *
2) Have you ever had thoughts around no longer wanting to live and/or thoughts about suicide? *
Comments; Please include what the thoughts were, what triggered them, if they were acted upon, if there are any past suicide attempts and detail any protective factors;
Your answer
Overall Suicide Risk *
3) Are you currently having difficulties in any of the following areas; Please tick all relevent boxes. *
Required
If yes, please provide details;
Your answer
Are you on any medication for psychological issues?
Your answer
What actions will be taken now to manage the identified client risks now? *
Your answer
What actions could be taken within the counselling sessions to manage the identified client risks? *
Your answer
Client accepted into service for Telephone Counselling? *
If the client has declined Telephone Counselling: Would the client like one of our Clinical Managers to call them to discuss this?
If you have determined that a request for Face to Face counselling is clinically appropriate, which of the inclusion criteria do they meet?
Please give details;
Your answer
Availability for counselling
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Morning (7-12)
Afternoon (12-5)
Evening (5-8)
Other specific times;
Your answer
First session booked? *
If the client has been accepted but the first session has not been booked for any reason, please can you notify the admin team via Slack or email; referrals@schoolwellbeing.com alternatively you can call us on 0800 023 6294.
Your answer
I have explained to the client that if a session is cancelled with less than 24 hours notice it may be deducted from their session entitlement and confirmed that they are in receipt the cancellation policy (emailed at referral stage)
Please confirm that you have explained the confidential nature of Counselling as well as outlining the limits to confidentiality ( that if throughout the work we become aware of things that pose serious risk to the client or others we have a professional duty to ensure their safety and therefore may need to break confidentiality)
Did the client get their first choice of session time and date?
If no, please provide details
Your answer
Name of allocated counsellor
Your answer
First Session time and date
Your answer
Counselling booked with triage practitioner?
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