Appendix D: Provider Worksheets
Survivor Current Needs
Date: ______Provider: ____________ Survivor Name: ___________________Location ____________
This session was conducted with (check all that apply):
Child Adolescent Adult Family Group
Provider: Use this form to document what the survivor needs most at this time. This form can be used to communicate with referral agencies to help promote continuity of care.
1. Circle the corresponding to difficulties the survivor is experiencing.
BEHAVIORAL
EMOTIONAL
PHYSICAL
COGNITIVE
Extreme disorientation
Excessive drug, alcohol, or prescription drug use
Isolation/withdrawal
High risk behavior
Regressive behavior
Separation anxiety
Violent behavior
Maladaptive coping
Other ____________
Acute stress reactions
Acute grief reactions
Sadness, tearful
Irritability, anger
Feeling anxious, fearful
Despair, hopeless
Feelings of guilt or shame
Feeling emotionally numb, disconnected
Other ____________
Headaches
Stomachaches
Sleep difficulties
Difficulty eating
Worsening of health conditions
Fatigue/exhaustion
Chronic agitation
Other ___________
Inability to accept/cope with death of loved one(s)
Distressing dreams or nightmares
Intrusive thoughts or images
Difficulty concentrating
Difficulty remembering
Difficulty making decisions
Preoccupation with death/ destruction
Other ________________
2. Circle corresponding to any other specific concerns
Past or preexisting trauma/psychological problems/substance abuse problems
Injured as a result of the disaster
At risk of losing life during the disaster
Loved one(s) missing or dead
Financial concerns
Displaced from home
Living arrangements
Lost job or school
Assisted with rescue/recovery
Has physical/emotional disability
Medication stabilization
Concerns about child/adolescent
Spiritual concerns
Other: ____________________________________________________________
3. Please make note of any other information that might be helpful in making a referral.
_______________________________________________________________________
______________________________________________________________________________
4. Referral
Within project (specify) _______________ Substance abuse treatment
Other disaster agencies Other community services
Professional mental health services Clergy
Medical treatment Other: ____________________________
5. Was the referral accepted by the individual? Yes No
1
Appendix D: Provider Worksheets
2
Psychological First Aid Components Provided
Date: ________ Provider: _________________ Location: _______________________
This session was conducted with (check all that apply):
Child Adolescent Adult Family Group
Place a checkmark in the box next to each component of Psychological First Aid that you provided in this session.
Contact and Engagement
Initiated contact in an appropriate manner Asked about immediate needs
Safety and Comfort
Took steps to insure immediate physical safety Gave information about the disaster/risks
Attended to physical comfort Encouraged social engagement
Attended to a child separated from parents Protected from additional trauma
Assisted with concern over missing loved one Assisted after death of loved one
Assisted with acute grief reactions Helped with talking to children
Attended to spiritual issues regarding death about death
Provided information about funeral issues Attended to traumatic grief
Helped survivors regarding death notification Helped survivors after body
Helped with confirmation of death to child identification
Stabilization
Helped with stabilization Used grounding technique
Gathered information for medication referral for stabilization
Information Gathering
Nature and severity of disaster experiences Death of a family member or friend
Concerns about ongoing threat Concerns about safety of loved one(s)
Physical/mental health illness and medication(s) Disaster-related losses
Extreme guilt or shame Thoughts of harming self or others
Availability of social support Prior alcohol or drug use
History of prior trauma and loss Concerns over developmental impact
Other: _______________________________
Practical Assistance
Helped to identify most immediate need(s) Helped to clarify need(s)
Helped to develop an action plan Helped with action to address the need
Connection with Social Supports
Facilitated access to primary support persons Discussed support seeking and giving
Modeled supportive behavior Engaged youth in activities
Helped problem-solve obtaining/giving social support
Information of Coping
Gave basic information about stress reactions Gave basic information on coping
Taught simple relaxation technique(s) Helped with family coping issues
Assisted with developmental concerns Assisted with anger management
Addressed negative emotions (shame/guilt) Helped with sleep problems
Addressed substance abuse problems
Linkage with Collaborative Services
Provided link to additional services service(s): ___________________________________
Promoted continuity of care ___________________________________
Provided handout(s) ________________________________
