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1 Mental Health Services Staff Referral Form 04/06/2012 Medical Evaluation (To Be Completed By The Medical Staff) Reason for Referral- Check and Explain All That Apply Actively Suicidal or Homicidal Self-Reported Diagnosis and/or Medication Self-Reported Problem/concern ERMA Documentation of Diagnosis/Problem List: Depression Verified Medication(s)- Personal Property or by Form Other Medical Concerns Check All That Apply Intoxicated Substance Withdrawal DM HEP HIV Seizures Head Trauma None Medical Action Plan Check All That Apply None Withdrawal Protocol (COWS/CIWA) Med Verification ROI Medical and/or Mental Health Where? County General Hospital Referral to HCP for Medical Condition Mental Health Evaluation (To Be Completed By Mental Health Staff) Date Reviewed 4/16/2012 Date of Mental Health Services Contact 04/09/2012 Intake Screening Reviewed Yes No Mental Health Disposition To Provider E-signed by Ashley Thomas on 04/06/ :35 PM ET Page 1 of 1 E-Signed by Joshua Hamilton on 04/16/ :45 PM ET

2 Mental Health Initial Assessment 04/07/2012 Reviewed Receiving Screen? Yes No Chief Complaint and History of Present illness- Subjective I/m was seen by mh due to a referral from medical reporting hx of tx for Bipolar Disorder and Major Depression at County General Hospital. Presently I/m reports that she is feeling sad and has no energy to keep up with her hygiene or report for counts. She describes a general pain that she feels but can t indicate a physical cause. COs report her crying and staring blankly at the walls. Psychiatric History ROI Verified: Outpatient Treatment: Current History None Where: N/A Inpatient Treatment: Current History None Where: County General Hospital Medication: Current History None List: Seroquel, Lamictal, Prozac, Lithium Family History: Violence History: Abuse History: Physical Sexual None Substance Abuse: Current History None ETOH THC Cocaine Other: unspecified Marital Status: Single Employed? Family/Significant Other supportive? Education (highest grade achieved):8 th grade Level of Cognitive Functioning: Average Page 1 of 4

3 Mental Health Initial Assessment 04/07/2012 Suicide Potential Screening Expresses thoughts of killing self Helplessness & Hopelessness (lack of future oriented thoughts) Suicide Plan or Instrument in possession Previous suicide attempt Family/Significant Other attempted or died by suicide Major problems other than legal Psychiatric History Currently under influence of Alcohol/Drugs Overly anxious, afraid, withdrawn Position of Respect in community- alleged crime is shocking in natureexpresses feelings of shame or embarrassment If there are any Yes answers to Red questions, or total # of Yes answers is 5 or more, a full mental health assessment should be performed. Medical History DM HTN HIV HEP Other History of Neurological disorders? Current Medications in jail See ERMA Legal History Current Charge: Larceny Date of Arrest: 04/01/2012 # of Arrests/Incarcerations: 6 Bound Over? Court/Release date scheduled: 06/01/2012 Assessment Appearance: Appropriate Meticulous Unclean Disheveled Bizarre Other Speech: Appropriate Expressive Loud Slowed Pressured Slurred Other Page 2 of 4

4 Mental Health Initial Assessment 04/07/2012 Mood: Appropriate Depressed Euphoric Anxious Angry Irritable Other Affect: Appropriate Tearful Blunted Flat Labile Hostile Other Thought Form: Coherent Circumstantial Tangential Loose Associations Poverty of Thought Flight of Ideas Other Thought Content: Appropriate Compulsive/Obsessive Thought Insertion Broadcasting Delusional Other Orientation: Person Place Purpose Time Intelligence: Above Average Average Below Average Developmentally Disabled Memory: Intact Immediate Recent Remote Insight: Intact Good Fair Poor Judgment: Intact Good Fair Poor Behavior: Appropriate Belligerent Agitated Withdrawn Assessment Summary: I/m presented with depression, low energy, crying spells and sleep disturbances. Her mood was depressed, affect was tearful, she didn t respond to many of this writer s questions. Her thought content was appropriate and she was oriented x4. I/m has intact memory, fair insight, fair judgment and withdrawn behavior. I/m denies ah/vh. I/m reports having been to County General Hospital and has taken psychiatric medications. I/m is not currently taking medications but does want something to take the pain away. I/m has been referred to the mh provider. MHS to f/u as needed. Joshua Hamilton, LCSW Page 3 of 4

5 Mental Health Initial Assessment 04/07/2012 Impression Axis I: R/O Bipolar Disorder I Axis II: Defer Axis III: Defer Axis IV: Legal, Employment, Housing Axis V: 40 Plan Mental Health Treatment not indicated at this time- MH will follow up as needed. Mental Health Specialist follow-up. Initiate/discontinue suicide precaution protocol. Referral to medical staff Referral to provider Requested collateral information, chart review. Allow 4 weeks for sobriety. Other: E-Signed by Joshua Hamilton on 04/10/ :50 PM ET Page 4 of 4

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7 Psychiatric Evaluation 04/09/2012 Chief Complaint and History of Present Illness It is so painful being Collette. Just waking up and having to face the day hurts. All I want to do is make it all go away. I just don t have energy for anything. This is a 33 yo WF who was referred by MHS. She presents with major depression and a history of bipolar disorder. She has not been keeping up with her hygiene or eating her food. She has to be repeatedly told to get out of her bunk and report for counts. Depression Mania Psychosis S I G E C A P S (Sleep disturb, Interest, Guilt/worthless, Energy loss, Conc dec, App chg, Psychomotor act chg, Sociality) G I D D I N E S S (Grandiosity, Irrit, Dec judgment, Distractibility, Inc GD act, Need of sl dec, Elev mood, Sp, Speedy thoughts) AH VH Disorg Del Paranoia Psychiatric History Previous Dx/Tx: She reports that she has been to County General Hospital. Records indicate previous dx of Depression and Bipolar Disorder. Long history of physical and sexual abuse as a child and adult. She took medications while hospitalized because they made her feel better. She never followed up for outpatient care. Substance Hx: ETOH THC Cocaine Other: Unspecified Medication Hx: Seroquel, Lamictal, Prozac, Lithium Family Hx: None known Abuse Hx: Physical Sexual None Legal History Current Charge 04/01/2012 Current Probation Past Arrests/Incarcerations 2011 November 8- December December January 25 Page 1 of 3

8 Psychiatric Evaluation 04/09/ July 8- October February 12- June 12 Abuse Hx: Physical Sexual Medical History DM HTN HIV HEP Other Medications None currently Allergies nkda Family Hx unknown Mental Status Exam Appearance/Behavior/Speech Dressed unclean, speech slowed, cooperative Mood Depressed Affect Tearful Sensorium A&Ox4, coherent Thought Appropriate Impression Axis I: Bipolar I Disorder Axis II: Defer Axis III: None reported Axis IV: Legal, Employment, Housing Axis V: 40 Plan Move to special needs. Start amitriptyline 50 mg. Refer to XYC Community Mental Health Center upon release. Page 2 of 3

9 Psychiatric Evaluation 04/09/2012 E-Signed by Francesca Tompkins on 04/11/ :50 AM ET Page 3 of 3

10 Follow-up Psychiatry Progress Note 04/21/2012 Subjective Seen for routine f/u apt. She reports consistency with medication. Describes feeling a little better. Does not appear to be as depressed as before. She seemed to be better groomed. Will be released from jail in a little over a month. XYZ CMHC liaison notified. Objective Mental Status Exam Sensorium: Alert Oriented X 3 Distractible Poor concentration Other Appearance: Well-kept Self-neglect Other Behavior: Calm Agitate Slowed Other Speech: Clear/coherent Spontaneous Pressured Poverty Other Mood: Euthymic Depressed Anxious Elevated Irritable Other Affect: Appropriate Inappropriate Constricted Blunted Other Thought Process: Goal Directed Disorganized Loose Associations Tangential Other Thought Content: Homicidal Suicidal Paranoid Hallucinations Delusions Other Memory Recent Intact Remote Intact Impaired Other Lab Results: None Medication Compliance? Page 1 of 2

11 Follow-up Psychiatry Progress Note 04/21/2012 Medication Side Effects: Nervousness AIMS Score (mark if baseline or follow-up): 0 Baseline 6 month follow-up N/A- based on current treatment regimen Response to Treatment: See above Diagnosis Axis I: Bipolar Disorder I Axis II: Defer Axis III: None reported Axis V: 60 Plan 1. Medication (does, frequency, duration): Continue amitriptyline 50 mg, daily 2 week supply upon release 2. Lab: None 3. Other (include F/U by MHP): Prn 4. Follow-Up Appointment: Yes f/u necessary No f/u necessary PRN 4 week appointment at XYC Community Mental Health Center E-Signed by Francesca Tompkins on 04/22/ :21 PM ET Page 2 of 2

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