De-Escalation Preference 2024

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This form is a guide to help you gather information and develop personalized de-escalation strategies. Person-centered trauma-informed de-escalation strategies are powerful prevention tools to help you avert difficult behaviors, and avoid restrain and seclusion. Use this form to develop strategies that are unique to your environment and to the individuals in your care. After clinical review, incorporate the following information into a clients behavior support or treatment plan. Please fill out with /for participant)

Email *

Name *

1.It is helpful for us to be aware of the things that can help you feel better when you are having a hard time. Have any of the following ever worked for you? We may not be able to offer all these alternatives, but I'd like us to work together to figure out how we can best help you *

Listening to music

Reading a book / newspaper

Sitting in the front of the bus

Watching TV (youtube etc)

Talking with a peer

Walking

Talking with staff

Calling a friend

calling a therapist(limited option)

Getting a hug

pounding some clay

punching a pillow

Physical exercise

writing in your diary/journal

Playing a computer game

Using ice on your body

Breathing exercise

putting your hands under running water/in water

going for a walk with staff

Lying down with a cold face cloth

wrapping up in a blanket

using a weighted vest

voluntary time out in a quiet place

Required

other *

Is there a person who's been helpful to you when you are upset *

If you are not able to give us information, do we have permission to call and speak to:(Name an Phone number) *

If you agree that we can call to get information, sign below with your name and date *

What are some of the triggers that make it more difficult for you when you are really upset? Are there particular "triggers" that will cause you to escalate

Being touched, isolated, door open, people in uniform, loud noise, yelling, scent, animals, bugs

Please explain

Is there anything that would assist you in feeling safe here? Please describe: *

A copy of your responses will be emailed to the address you provided.

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