Person discloses experience of torture or other traumatic events with or without prompting. Note: Person discloses injuries or pain which is/are the result of torture, sexual assault or other form of violence. Note: Person discloses suicidal ideation or self harm [Note: Please refer to an emergency service if an immediate risk] Please Specify: Person is seeking referral as a result of family relationship difficulties. Note: Psychological screening: Observations (no questions required) or spontaneous disclosures of any the following: ADULTS (only) CHILDREN and ADOLESCENTS (only) Crying a lot Sleep problems-too much or too little Intense/persistent emotional distress Nightmares Aggressive behaviour or persistent anger Severe social withdrawal Fears of going out/going to work or other fears Crying a lot Severe social withdrawal or appears Lots of worries uncommunicative Repeated expressions of hopelessness Hyper-alert Many persistent worries Aggressive behaviour or persistent anger On alert for things going wrong Out of control behaviour Overreacting to noises etc in environment Bed-wetting Find images or memories distressing Not wanting to go to school Risk-taking behaviours Peculiar appearance, behaviour or speech Persistent headaches or other aches Poor memory / concentration Poor peer relationships Alcohol or substance abuse Very clingy behaviour of children Poor self care, household care Persistent physical ailments with no medical cause Alcohol or substance abuse (especially for e.g. headaches, neck pain, stomach pain adolescents) Not responding to needs of children, emotional Frequent tantrums distance Overacting to minor incidents Persistent and severe sleep difficulties/ nightmares Expressed threat to harm self or others * Signs of family conflict Bizarre behaviours Specify: Person appears disoriented, incoherent or confused Person expresses bizarre or illogical belief Specify: Expressed threat to harm self or others * Person discloses or family member discloses that she/he suffers from a mental health problem and/or that she/he is being treated for a mental health problem (or their words for this) * Where there is an immediate risk of harm to self or others please refer to an emergency service. For non-immediate threats please provide a description above
Person discloses experience of torture or other traumatic events with or without prompting. Note: Person discloses injuries or pain which is/are the result of torture, sexual assault or other form of violence. Note: Person discloses suicidal ideation or self harm [Note: Please refer to an emergency service if an immediate risk] Please Specify: Person is seeking referral as a result of family relationship difficulties. Note: Psychological screening: Observations (no questions required) or spontaneous disclosures of any the following: ADULTS (only) CHILDREN and ADOLESCENTS (only) Crying a lot Sleep problems-too much or too little Intense/persistent emotional distress Nightmares Aggressive behaviour or persistent anger Severe social withdrawal Fears of going out/going to work or other fears Crying a lot Severe social withdrawal or appears uncommunicative Lots of worries Repeated expressions of hopelessness Hyper-alert Many persistent worries Aggressive behaviour or persistent anger On alert for things going wrong Out of control behaviour Overreacting to noises etc in environment Bed-wetting Find images or memories distressing Not wanting to go to school Peculiar appearance, behaviour or speech Risk-taking behaviours Poor memory / concentration Persistent headaches or other aches Alcohol or substance abuse Poor peer relationships Poor self care, household care Very clingy behaviour of children Persistent physical ailments with no medical cause e.g. headaches, neck pain, stomach pain Alcohol or substance abuse (especially for adolescents) Not responding to needs of children, emotional distance Frequent tantrums Persistent and severe sleep difficulties/ nightmares Overacting to minor incidents Signs of family conflict Expressed threat to harm self or others * Person appears disoriented, incoherent or confused Bizarre behaviours Specify: Person expresses bizarre or illogical belief Specify: Expressed threat to harm self or others * Person discloses or family member discloses that she/he suffers from a mental health problem and/or that she/he is being treated for a mental health problem (or their words for this) * Where there is an immediate risk of harm to self or others please refer to an emergency service. For non-immediate threats please provide a description above
QPASTT-Referral-form-2014.docx