De-Escalation Preferences Form
This form is a guide to gathering information with clients for the development of strategies to de-escalate agitation and distress so that restraint and seclusion can be averted.
Student Name: ______Date: ______
1. It is helpful for us to be aware of the things that can help you feel better when you’re 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 while you’re here.
___ Voluntary time out in your room.
___ Listening to music.
___ Voluntary time out in a quiet room.
___ Reading a newspaper/book.
___ Watching a movie.
___ Talking with another consumer/student.
___ Pacing the halls.
___ Talking with staff.
___ Having your hand held.
___ Receiving a hug.
___ Pounding some clay.
___ Punching a pillow.
___ Physical exercise.
___ Writing in a diary/journal.
___ Playing a computer game.
___ Deep breathing exercises.
___ Putting your hands under cold water.
___ Going for a walk with staff.
___ Lying down with a cold facecloth.
___ Wrapping up in a blanket.
___ Using a weighted vest.
___ Other (please list):
______
______
______
______
2. Is there a person who has been helpful to you when you’ve been upset? (Y/N):
If he/she is available, would you like that person to come and see when you’re upset? (Y/N)
Is there someone at school you would like to talk to when you are becoming upset? (Y/N)
3. What are some of the things that make it more difficult for you when you’re already upset? Are there particular “triggers” that you know will cause you to escalate?
___ Being touched.
___ Being isolated.
___ Bedroom door open.
___ People in uniform.
___ A particular time of day (when?).
___ A time of the year (when?).
___ Loud noise.
___ Yelling.
___ Specific scents (please explain):
______
___ Not having control/input (explain):
______
___ Others (please list):
______
______
______
4. Have you ever been restrained at school?
When? ______
Where? ______
Please describe what happened. ______
5. Do you have a preference regarding the gender of staff assigned to you during and immediately after a restraint?
___ Female staff
___ Male staff
___ No preference
6. Is there anything that would assist you in feeling safe during a restraint? Please describe.
______
______
______
______
Student Signature ______Date______
Witness______Date ______