CSS Correctional Service System
|
|
- Edward Price
- 6 years ago
- Views:
Transcription
1 Mental Health Services Staff Referral Form 09/20/2007 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: Schizophrenia Verified Medication(s)- Personal Property or by Form Other Yes No 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 Yes No Mental Health Evaluation (To Be Completed By Mental Health Staff) Date Reviewed 9/20/2007 Date of Mental Health Services Contact 09/21/2007 Intake Screening Reviewed Yes No Mental Health Disposition To Provider E-signed by Ashley Thomas on 09/20/ :35 PM ET Page 1 of 1 E-Signed by Joshua Hamilton on 09/24/ :45 PM ET
2 Mental Health Initial Assessment 09/20/2007 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 PTSD and Bipolar Disorder at County General Hospital. Presently I/m reports that he is worried about the listening devices that government put in his room and complains of the radio transmissions that he can hear that are keeping him up at night. He asked for all of the talking to stop. Psychiatric History ROI Verified: Yes No Outpatient Treatment: Current History None Where: N/A Inpatient Treatment: Current History None Where: County General Hospital Medication: Current History None List: Paroxetine, Lithobid, Zyprexa, Benadryl Family History: Violence History: Abuse History: Physical Sexual None Substance Abuse: Current History None ETOH THC Cocaine Other: Heroin Marital Status: Single Employed? Family/Significant Other supportive? Yes No Education (highest grade achieved): High school diploma Level of Cognitive Functioning: Average Page 1 of 4
3 Mental Health Initial Assessment 09/20/2007 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 Yes No Yes No Yes No 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: Criminal Trespassing Date of Arrest: 09/19/2007 # of Arrests/Incarcerations: 5 Bound Over? Court/Release date scheduled: 10/19/2007 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 09/20/2007 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 an anxious mood, tangential thought form (I/m had to be re-directed throughout the assessment), pressured speech, flat affect, and delusional thought content. I/m reports that he is from Middleton, PA and was discharged from the Army in He has been homeless since his discharge and living under Barlow s Bridge in Rickett s Glen Park. I/m believes that the government is listening to everything and everyone. He reports that he can hear their radio transmissions that give him instructions and scare him. He is hyper vigilant about checking his surroundings and his eyes dart around when he isn t answering a direct question. I/m denies ah/vh but does report hearing things that others can not hear. I/m reports having been to County General Hospital and Page 3 of 4
5 Mental Health Initial Assessment 09/20/2007 has taken psychiatric medications. I/m is not currently taking medications and does not believe that he needs any. I/m has been referred to the mh provider. MHS to f/u as needed. Joshua Hamilton, LCSW Impression Axis I: R/O Schizophrenia, Paranoid Type Axis II: Defer Axis III: Defer Axis IV: Legal, Employment, Housing Axis V: 45 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 09/24/ :50 PM ET Page 4 of 4
6 Psychiatric Evaluation 010/03/2007 Chief Complaint and History of Present Illness I need to be in a room without any listening devices. Please do something about the constant government radios. I can hear them talking and they keep me from sleeping. This is a 29 yo AAM who was referred by MHS. He presents with paranoia and auditory hallucinations. Talks about the government s radio transmissions and listening and tracking devices that have been implanted in him and placed in his cell. 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: He reports that he has been to County General Hospital. Records indicate previous dx of PTSD and Bipolar Disorder. He took medications there and took the medications that were supplied to him because they made him feel better. He never followed up for outpatient care. Substance Hx: ETOH THC Cocaine Other: Heroin Medication Hx: Paroxetine, Lithobid, Zyprexa, Benadryl Family Hx: None known Abuse Hx: Physical Sexual None Legal History Current Charge 09/19/2007 Current Probation Past Arrests/Incarcerations Abuse Hx: Physical Sexual Page 1 of 2
7 Psychiatric Evaluation 010/03/2007 Medical History DM HTN HIV HEP Other Medications None currently Allergies nkda Family Hx unknown Mental Status Exam Appearance/Behavior/Speech Dressed appropriately, speech wnl, cooperative Mood Mildly anxious Affect Flat Sensorium A&Ox4, coherent Thought Paranoid Impression Axis I: Schizophrenia, Paranoid Type Axis II: Defer Axis III: None reported Axis IV: Legal, Employment, Housing Axis V: 45 Plan Move to special needs. Start haloperidol 10 mg, amitriptyline 75 mg. Refer to XYC Community Mental Health Center upon release. E-Signed by Francesca Tompkins on 10/05/ :50 AM ET Page 2 of 2
8
9
10 Follow-up Psychiatry Progress Note 010/17/2007 Subjective Seen for routine f/u apt. He reports consistency with medication. Describes feeling better. Does not appear to be as preoccupied with the voices from the radio. Only asked about the government tracking devices once. Will be released from jail in a few days. 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 Page 1 of 2
11 Follow-up Psychiatry Progress Note 010/17/2007 Medication Compliance? Yes No Medication Side Effects: Mild tdk 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: Schizophrenia, Paranoid Type Axis II: Defer Axis III: None reported Axis V: 60 Plan 1. Medication (does, frequency, duration): Continue haloperidol 10 mg, amitriptyline 75 mg, daily Add Benadryl 25 mg prn 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 2 week appointment at XYC Community Mental Health Center E-Signed by Francesca Tompkins on 10/19/ :21 PM ET Page 2 of 2
12 Follow-up Psychiatry Progress Note /17/2012 Subjective Seen due to multiple disciplinary reports. I/m not reporting for count. He has been sitting in the cell talking rapidly to himself. Is preoccupied with the voices in the radio and struggles to focus on the questions of this writer. I/m seems very anxious and is constantly scanning the room. He has not been taking medications. I/m known to this writer. 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: Page 1 of 2
13 Follow-up Psychiatry Progress Note /17/2012 None Medication Compliance? Yes No Medication Side Effects: Mild tdk 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: Schizophrenia, Paranoid Type Axis II: Defer Axis III: None reported Axis V: 35 Plan 1. Medication (does, frequency, duration): Continue haloperidol 10 mg, amitriptyline 75 mg, daily, Benadryl 25 mg prn 2. Lab: None 3. Other (include F/U by MHP): F/U in 1 week to assess medication compliance 4. Follow-Up Appointment: Yes f/u necessary No f/u necessary PRN 1 week E-Signed by Francesca Tompkins on 02/19/ :33 PM ET Page 2 of 2
14 Psychiatric Evaluation /24/2012 Chief Complaint and History of Present Illness I/m believes that the COs are trying to harm him. He is very suspicious of the radios on their belts and gets very nervous and anxious when an officer is around. He reports only sleeping a couple hours at night because he has to keep watch. Staff report that he is not eating his food. He believes that the people preparing the food are poisoning it and has requested pre-packaged food. 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: I/m has had many inpatient hospitalizations at County General Hospital. Records indicate previous dx of PTSD, Bipolar Disorder and most recently Schizophrenia. He has a history of non-compliance with medication. He does not attend outpatient treatment. Substance Hx: ETOH THC Cocaine Other: Heroin Medication Hx: Paroxetine, Lithobid, Zyprexa, Haloperidol, Benadryl Family Hx: None known Abuse Hx: Physical Sexual None Legal History Current Charge 02/12/2012 Current Probation Yes No Previously required to attend Local Charities Substance Abuse Treatment Program for 60 days in December Completed February 1, Page 1 of 3
15 Psychiatric Evaluation /24/2012 Past Arrests/Incarcerations 2011 November April 4-June February 2-March August 30-September May 3-May August April 1-June September 20- October 20 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 appropriately, speech wnl, uncooperative Mood Mildly anxious Affect Flat Sensorium A&Ox4, disorganized Thought Paranoid Impression Axis I: Schizophrenia, Paranoid Type Axis II: Defer Axis III: Hepatitis C Axis IV: Legal, Employment, Housing Page 2 of 3
16 Psychiatric Evaluation /24/2012 Axis V: 45 Plan Move to special needs. Start haloperidol 10 mg, amitriptyline 75 mg. Refer to XYC Community Mental Health Center upon release. E-Signed by Francesca Tompkins on 02/27/ :38 AM ET Page 3 of 3
CSS Correctional Service System
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
More informationInitial Evaluation Template
Demographic Information (Please complete all questions on this form) Member Name: Date: Name: Address: Phone (Home): Phone (Work): Date of Birth: Social Security #: Guardianship (for children and adults
More informationHawthorne Veteran and Family Resource Center. Recuperative Care Program Referral Form. 250 N. Ash Street. Escondido, CA 92027
Hawthorne Veteran and Family Resource Center Recuperative Care Program Referral Form 250 N. Ash Street Escondido, CA 92027 Referring party: Date of Referral: / / Contact number: ( ) - Last admission: /
More informationSAMPLE INITIAL EVALUATION TEMPLATE
I. Demographic Information Date: SAMPLE INITIAL EVALUATION TEMPLATE Name: Address: Phone (Home/Cell): Phone (Work): Date of Birth: Guardianship (for children and adults when applicable): Marital Status:
More informationCounty General Hospital 546 That Street Some Town, YY DISCHARGE SUMMARY
County General Hospital 546 That Street Some Town, YY 12345 111-222-9998 DISCHARGE SUMMARY PATIENT: Michael F. Byrnes UNIT#: 345678 ADMISSION DATE: June 5, 2006 ACCT#: 98734512 DISCHARGE DATE: June 6,
More informationINITIAL MENTAL HEALTH ASSESSMENT
1. Identifying Information (age, gender, ethnicity, preferred language, relationship status, sexual orientation, gender identity, living arrangement): 2. Presenting Mental Health Problem (referral source,
More informationTriage/Low Demand Shelter Screening Form
Triage/Low Demand Shelter Screening Form Arrest History Date: Charge Type: Charge: Arrest Date: Was client Convicted? Conviction Date: City: State: County: SPN/Jacket # (Can be found on the www.sheriffleefl.org)
More informationInitial Substance Use Assessment
Date of Assessment: Source of Referral: Choose an item. Persons Present: Client and Provider only Transportation Assistance Needed: Yes No Member has a Primary Care Physician (PCP)? Yes No If yes PCP,
More informationCENTRAL NEW YORK SERVICES DUAL RECOVERY PROGRAM BIO-PSYCHO-SOCIAL ASSESSMENT. Name: DOB: SSN: Race: Sex: Marital Status: # of Children:
CENTRAL NEW YORK SERVICES DUAL RECOVERY PROGRAM BIO-PSYCHO-SOCIAL ASSESSMENT Date of Intake: Therapist: I. IDENTIFYING INFORMATION Name: DOB: SSN: Address: Race: Sex: Marital Status: # of Children: Living
More informationSubstance Use Disorder Intake/Assessment Form
Date of Birth: Address: City, State, Zip: Parent/Guardian (if applicable): Primary Phone #: Name of Emergency Contact (EC): Relationship to EC: Emergency Contact Phone #: Referral Source: Cultural and
More informationCAMS SUICIDE STATUS FORM 4 (SSF-4) INITIAL SESSION Patient: Clinician: Date: Time: Section A (Patient):
CAMS SUICIDE STATUS FORM 4 (SSF-4) INITIAL SESSION Patient: Clinician: Date: Time: Section A (Patient): Rank Rate and fill out each item according to how you feel right now. Then rank in order of importance
More informationThe Psychiatric Interview
The Psychiatric Interview What are the goals of the psychiatric interview? Establishment of a working relationship Gathering relevant data Diagnosis and formulation Assessing change in mental status and
More informationADULT INTAKE/PSYCHOSOCIAL ASSESSMENT. Name: Date: Referred by:
ADULT INTAKE/PSYCHOSOCIAL ASSESSMENT Name: Date: Referred by: Date of Birth: SSN: Identifying Information (age, marital status, ethnicity, and sex) 1. Reason for Referral: (Why are you here? Describe problems,
More information(Check if applicable)
Source of Information: Patient Family Significant Other Records Language Line utilized to complete the Screening: If checked, Name of Language Line Interpreter: (Check if applicable) 1. Admission Status
More informationUnderstanding Mental Illness A Review of the Disorders
Understanding Mental Illness A Review of the Disorders Objectives Define and describe mental illness To be able to recognize signs, symptoms, and behaviors of the major categories of mental illness Recognition
More informationParanoid Schizophrenia. Prepared by : Noor Al-Hakami pharm-d candidate KSU
Paranoid Schizophrenia Prepared by : Noor Al-Hakami pharm-d candidate KSU Paranoid schizophrenia is one of several types of schizophrenia which affect around 40 % of people with schizophrenia It tends
More informationName:, Sex:, Age: Ethnicity, Race. Date of Birth:, address: Address:, City: State:, County,, Zip: Telephone numbers: Home: ( ),Work: ( )
Adult Patient Information Name:, Sex:, Age: Ethnicity, Race Date of Birth:, Email address: Address:, City: State:, County,, Zip: Telephone numbers: Home: ( ),Work: ( ) Cell: ( ) Referral by: Person to
More informationUniversal Mental Health & Substance Abuse Psychosocial Assessment
Agency Address Phone Client Name Date: Social Security # DOB: Client s Legal Status: Legal Guardian Name: Phone: Relationship to Client: Emergency Contact: Phone number: Relationship to you: 1. What brings
More informationClinical Considerations for a Strength-Based Intake Assessment
Clinical Considerations for a Strength-Based Intake Assessment Initial Comments/ Assessment Summary 1. Client Demographics - Name: Age: Gender: Race: Note: Domain areas assess the identified child only
More informationDIAN KUANG 馬 萬. Giovanni Maciocia
DIAN KUANG 癫狂 馬 萬 Giovanni Maciocia 里 BIPOLAR DISORDER (MANIC-DEPRESSION) DIAN Qi and Phlegm stagnating Heart and Spleen deficiency with Phlegm Qi deficiency with Phlegm KUANG Phlegm-Fire harassing upwards
More informationTherapy Resources of Morris County, LLC
NEW CLIENT ASSESSMENT (CLINICIAN COMPLETES) Client NAME: DOB: DATE: 1. PRESENTING PROBLEM (s): Include reasons for seeking treatment now, source of information and reliability. Describe in behavioral terms
More informationSACRED HEART HOSPITAL 421 Chew Street Allentown, PA EAC REFERRAL PACKET REQUIREMENTS
EAC REFERRAL PACKET REQUIREMENTS Please refer to the following in order to adhere to the standard requirements for the referral packet submission to Sacred Heart Hospital EAC: Case Management - Name -
More informationPsychosocial Factors in a TB Patient Adriana Vasquez, MD July 30, 2008
Becoming a TB Nurse Expert San Antonio, Texas July 30-31, 2008 Psychosocial Factors in a TB Patient Adriana Vasquez, MD July 30, 2008 TUBERCULOSIS and MENTAL ILLNESS Adriana Vasquez, MD Staff physician
More informationMental Status Exam 101. A Concurrent Disorders Lunch & Learn
Mental Status Exam 101 A Concurrent Disorders Lunch & Learn 2 HELLO! Bradley Labuguen RN BScN MHM CPMHN(c) blabugue@stjosham.on.ca Nurse Educator St. Joseph s Healthcare Hamilton 3 Objectives Time: 50
More informationSubstance Abuse History: 5 to 6 drinks every 2 weeks. No recent use of alcohol, tobacco, or drugs.
Date of Admission: [DATE] Date of Discharge: [DATE] History of Present Illness: This is a 39-year-old Caucasian married male with no previous psych history who is brought in by his wife on the urging of
More informationMCPAP Clinical Conversations:
MCPAP Clinical Conversations: After the screen: A Practical Approach to Mental Health Assessment in the Pediatric Primary Care Setting Barry Sarvet, MD Professor and Chair of Psychiatry, UMMS-Baystate
More informationPSYCHIATRIC CLINIC, LLC 123 Main Street Anywhere, US (O) (F) Nesmith, Kelly.
Page 1 of 7 PSYCHIATRIC CLINIC, LLC 123 Main Street Anywhere, US 12345-6789 555-678-9100 (O) 555-678-9111 (F) DATE ADMITTED: 4/24/2017 DATE DISCHARGED: This discharge summary consists of 1. Initial Assessment
More informationManagement of a HIV-infected patient with a psychiatric disorder
Management of a HIV-infected patient with a psychiatric disorder Maria Ferrara, Modena, Italia Guida Da Ponte, Lisboa, Portugal Jordi Blanch, Barcelona Main complaint Mr M is a 30-year-old HIV+ man In
More informationMood Disorders Workshop Dr Andrew Howie / Dr Tony Fernando Psychological Medicine Faculty of Medical and Health Sciences University of Auckland
Mood Disorders Workshop 2010 Dr Andrew Howie / Dr Tony Fernando Psychological Medicine Faculty of Medical and Health Sciences University of Auckland Goals To learn about the clinical presentation of mood
More informationSummary of presenting problem: Diagnosis: Axis I ... Axis II. Axis III. Axis IV. Axis V GAF = Services recommended: Therapy. Diagnostic assessment
Client name: Client ID: DOB: / / Date: / / Summary of presenting problem: Diagnosis: Axis I Axis II Axis III Axis IV Axis V GAF = Services recommended: Therapy Diagnostic assessment Referral Psychological
More informationClient: Date of Birth: Date of Report: MENTAL STATUS EXAMINATION REPORT 1. Identifying Information
Client: Date of Birth: MENTAL STATUS EXAMINATION REPORT 1. Identifying Information Date of Report: 2. Reason for Assessment (Please indicate referral source, precipitating circumstances and chief complaints)
More informationSUBJECT: Suicide Risk Screening and Assessment of Individuals in State Hospitals and State-Operated Crisis Stabilization Programs
DBHDD SUBJECT: Suicide Risk Screening and Assessment of Individuals in State Hospitals and State-Operated Crisis Stabilization Programs Policy: 03-504 Page 2 of 3 Hospital and CSP Staff Awareness regarding
More informationMental Health Issues in Nursing Homes. I m glad you asked.
Mental Health Issues in Nursing Homes I m glad you asked. I m glad you asked Susan Wehry, M.D. Associate Professor of Psychiatry, College of Medicine, University of Vermont Consultant, State of Vermont
More informationName: ASSESSMENT. MEDICAL HISTORY: Medical Conditions Condition No/Yes Additional Information (onset, treatment, etc.
ASSESSMENT Name: Date of Birth: Age: Social Security #: Gender: Male Female Race/Ethnicity: Preferred Language: Address: Phone Number: E-mail address: AHCCCS Coverage: Yes, If yes AHCCCS ID #: and AHCCCS
More informationDepartment of Public Welfare PSYCHOLOGICAL IMPAIRMENT REPORT
Department of Public Welfare PSYCHOLOGICAL IMPAIRMENT REPORT The purpose of this report is to outline the information needed to make a disability determination. This is not a required format; however,
More informationEmergency Department Mental Health Triage & Risk Assessment Tool Training Package. Authored by: Paul Devlin, Gerry Wright & Dr Keith McKillop
Emergency Department Mental Health Triage & Risk Assessment Tool Training Package Authored by: Paul Devlin, Gerry Wright & Dr Keith McKillop Learning Outcomes Describe how you would complete the GG&C Emergency
More information2015 Behavioral Medicine Resident Chart Documentation. Laura Sullivan, MSW, CPC Compliance Auditor
2015 Behavioral Medicine Resident Chart Documentation Laura Sullivan, MSW, CPC Compliance Auditor 1 Legal Stuff The information provided here is being provided by a nonlawyer and should not be construed
More informationTHE PSYCHIATRIC MEDICAL HISTORY. Prof. Paz García-Portilla
THE PSYCHIATRIC MEDICAL HISTORY Prof. Paz García-Portilla MEDICAL HISTORY (HX) Clinical data set gained by a physician by asking specific questions to the patient (or proxy), with the aim of obtaining
More informationASSESSMENT. MEDICAL HISTORY: Medical Conditions Condition No/Yes Additional Information (onset, treatment, etc.) Diabetes No Yes Heart Disease (High
ASSESSMENT Name: Date of Birth: Age: Social Security #: Gender: Male Female Race/Ethnicity: Preferred Language: Address: Phone Number: E-mail address: Preferred Pronouns: AHCCCS Coverage: Yes: If yes AHCCCS
More informationTime... Client Company:... Client Name/s:... Surname:...
Practitioner s Name:. 1stSession Date: Time.... Client Company:... Client Name/s:.... Surname:... PROBLEM DETAILS- Service Provisioning 1. Problem Details Please note: In the event of a formal referral,
More informationACOEM Commercial Driver Medical Examiner Training Program
ACOEM Commercial Driver Medical Examiner Training Program Module 7: Psychological Psychological 49 CFR 391.41(b)(9) "A person is physically qualified to drive a commercial motor vehicle if that person
More informationWinter Night Shelters and Mental Healh Barney Wells, Enabling Assessment Service London.
Winter Night Shelters and Mental Healh Barney Wells, Enabling Assessment Service London. Introduction goals of session - What is mental health - What is interaction between poor mental health and CWS -
More informationHandout 2: Understanding Psychotic Illness
Handout 2: Understanding Psychotic Illness A Psychosis refers to a state where a person loses contact with reality. The word is derived from the Latin words "psyche" meaning mind and "osis" meaning illness.
More informationMETHAMPHETAMINE: The Good, The Bad, And The Toxic
METHAMPHETAMINE: The Good, The Bad, And The Toxic In the beginning Stay awake The GOOD Chemically close to Ritalin attention improvements, learning Weight loss Feel in control of life, time Feel productive
More informationADULT History Form (To be filled out by the person seeking treatment)
1 ADULT History Form (To be filled out by the person seeking treatment) Client s Name Date: SS# - - DOB: / / Age: Person completing this form: Client Other: (give name) Who referred you to Namsate Counseling?
More informationChild/ Adolescent Questionnaire
Oconee Center for Behavioral Health 1360 Caduceus Way Building 400, Suite 102 Tel 706-286-8442 Fax 706-310-6907 Child/ Adolescent Questionnaire Patient s Name: Date of Birth: / / Patient s Birthplace:
More informationPSYCHIATRIC MENTAL STATUS EXAMINATION. Jerry L. Dennis, M.D. Medical Director, ADHS/DBHS
PSYCHIATRIC MENTAL STATUS EXAMINATION Jerry L. Dennis, M.D. Medical Director, ADHS/DBHS Mental Status Examination General Considerations Based on Observations During the Assessment Process Spontaneity
More information2016 Behavioral Medicine Resident Chart Documentation. Laura Sullivan, MSW, CPC Compliance Auditor
2016 Behavioral Medicine Resident Chart Documentation Laura Sullivan, MSW, CPC Compliance Auditor 1 Legal Stuff The information provided here is being provided by a nonlawyer and should not be construed
More informationHELPING A PERSON WITH SCHIZOPHRENIA
HELPING A PERSON WITH SCHIZOPHRENIA OVERCOMING CHALLENGES WHILE TAKING CARE OF YOURSELF The love and support of family plays an important role in schizophrenia treatment and recovery. If someone close
More informationNew Service Provider Provider Type Provider Name Phone Ext
Substance Abuse Adult Assessment AST022 Assessment Information Assessment Number Assessment Date Assessment Type Contact Type Assessment Site Referred by Client Issue Presenting Problem Expectations Service
More informationIntake Form. Presenting Problems and Concerns. When did it start and how does it affect you:
Intake Form Name: Date: Presenting Problems and Concerns Describe the problem that brought you here today: When did it start and how does it affect you: Estimate the severity of the above problem: Mild
More informationClient Intake Form. Briefly describe the reason(s) you are seeking psychotherapy at this time:
Client Intake Form Thank you for taking the time to openly and honestly answer the questions below. Your genuine responses are appreciated, as all information provided will assist your therapist to better
More informationSAMPLE BIOPSYCHOSOCIAL ASSESSMENT. Henry Ford Cottage Hospital. Date of Evaluation: Start Time: End Time:
BIPSYCHSCIAL ASSESSMENT Date of Evaluation: Start Time: End Time: Informants: (check all) Patient Guardian Family ther Names: Circumstances of Admission (include vulnerability factors, prompting event,
More informationTB Intensive San Antonio, Texas December 1-3, 2010
TB Intensive San Antonio, Texas December 1-3, 2010 Handling Mental Illness Adriana Vasquez, MD; TCID December 2, 2010 Handling Mental Illness in the TB Patient with Case Illustrations TB Intensive Adriana
More information3/9/2017. A module within the 8 hour Responding to Crisis Course. Our purpose
A module within the 8 hour Responding to Crisis Course Our purpose 1 What is mental Illness Definition of Mental Illness A syndrome characterized by clinically significant disturbance in an individual
More informationMINOR CLIENT HISTORY
MINOR CLIENT HISTORY CLIENT NAME: DATE: FAMILY & SOCIAL BACKGROUND: Please list and describe your child s or teen s current family members (immediate, extended, adopted, etc.) NAME RELATIONSHIP AGE OCCUPATION
More informationBRIEF PSYCHIATRIC RATING SCALE ANCHORED. Introduce all questions with During the past week have you..
BRIEF PSYCHIATRIC RATING SCALE ANCHORED Introduce all questions with During the past week have you.. *1. SOMATIC CONCERN: Degree of concern over present bodily health. Rate the degree to which physical
More informationMental Health Series for Perinatal Prescribers. Severe postpartum syndromes
Mental Health Series for Perinatal Prescribers Severe postpartum syndromes 2 Maternal Filicides Acutely psychotic - 24% Depression Altruistic - 56% to relieve suffering associated with suicide 80% due
More informationCase Study Mental Evaluation
Case Study Mental Evaluation Facts Service: 3/65 11/69 8/06 Regional Office (RO) granted service connection (S/C) for posttraumatic stress disorder (PTSD) at 30% from 3/06 7/07 Statement of Case (SOC)
More informationPreferred Name (s): Local Address: City: State: Zip: Permanent Address: City: State: Zip: Years of Education: Occupation: Gender: M F
Today Date: Client Name(s) : Psychological Consultants Northgate Center 1210 ½ -7 th Street NW, Suite 216 Rochester, MN 55901 www.psychologicalconsultants1.com Office: (507) 252-9292 Fax: (507) 252-9203
More informationDisability Risk Management in Today s Workforce: Chronic Pain and Opioid Addiction
Disability Risk Management in Today s Workforce: Chronic Pain and Opioid Addiction Michael V. Genovese, M.D., J.D. Chief Medical Advisor, Acadia Healthcare Recovery Division The vast majority of painful
More informationBehavioral Emergencies. Lesson Goal. Lesson Objectives 9/10/2012
Behavioral Emergencies Lesson Goal Recognize, assess, & treat patients with behavioral emergencies, including patients with psychiatric history & substance abuse Lesson Objectives Define these terms: Suicide
More informationNORTHLAKE YOUTH ACADEMY Psychiatric Residential Treatment Facility Hwy. 190 Mandeville, Louisiana Phone: Fax:
NORTHLAKE YOUTH ACADEMY Psychiatric Residential Treatment Facility 23515 Hwy. 190 Mandeville, Louisiana 70470 Phone: 985-626-6534 Fax: 985-626-6398 Completed by: Date: Resident s Name: Resident s Date
More informationWarning Signs of Mental Illness in Children/Adolescents. Beth Confer, MA, LPC Director, Community Relations Clarity Child Guidance Center
Warning Signs of Mental Illness in Children/Adolescents Beth Confer, MA, LPC Director, Community Relations Clarity Child Guidance Center Identify At least 5 warning signs of mental illness in children
More informationCLIENT INFORMATION FORM. Name: Date: Address: Gender: City: State: Zip: Date of Birth: Social Security Number:
Name: Address: Gender: City: State: Zip: Date of Birth: Social Security Number: Contact Telephone Numbers Please complete relevant information and indicate the number at which you wish to be contacted
More informationCLIENT HISTORY CLIENT LEGAL NAME: CLIENT PREFERRED NAME:
CLIENT HISTORY CLIENT LEGAL NAME: DATE: CLIENT PREFERRED NAME: FAMILY & SOCIAL BACKGROUND Please list and describe your current family members (immediate, extended, adopted, etc.) and/or other members
More informationDemographic Information Form
PATIENT INFORMATION Demographic Information Form / / Mailing: Male Female SSN#: - - Home Cell Relationship Status (circle one): Single / Married / Divorced / Widowed / Other: ( ) - ( ) - (Preferred Phone
More informationTelepsychiatry In Rural Nursing Homes
Telepsychiatry In Rural Nursing Homes Andrew Rosenzweig MD, MPH Chief Medical Officer, Forefront TeleCare Assistant Clinical Professor, Brown University cope of Problem: evere Unmet Need Over 5,000 rural/hpa
More informationPsychosis, Mood, and Personality: A Clinical Perspective
Psychosis, Mood, and Personality: A Clinical Perspective John R. Chamberlain, M.D. Assistant Director, Psychiatry and the Law Program Assistant Clinical Professor University of California San Francisco
More informationBEHAVIORAL HEALTH PLANNING COUNCIL Adult/Substance Abuse/Medicaid Subcommittee
BEHAVIORAL HEALTH PLANNING COUNCIL Adult/Substance Abuse/Medicaid Subcommittee Marcello Maviglia, MD, MPH Loretta Cordova, LMSW,CCM Donald Hume, Peer Support Specialist Supervisor Improved Quality of Life
More informationChapter 29. Caring for Persons With Mental Health Disorders
Chapter 29 Caring for Persons With Mental Health Disorders The Whole Person The whole person has physical, social, psychological, and spiritual parts. Mental relates to the mind. Mental health and mental
More informationAddress: Spouse/Partner Name: Phone: Address:
Adult Wellness Assessment Please take a few minutes to fill out this form. The information will be helpful in better understanding your individual needs and situation. Thank you. Personal Information Name:
More informationMental Health Rotation Educational Goals & Objectives
Mental Health Rotation Educational Goals & Objectives Mental illness is prevalent in the general population and is commonly seen and treated in the office of the primary care provider. Educational experiences
More informationA-Z of Mental Health Problems
Mental health problems can cover a broad range of disorders, but the common characteristic is that they all affect the affected person s personality, thought processes or social interactions. They can
More informationMental Health Triage Algorithm for use by Non-Mental Health Providers in Acute Settings Peter Yellowlees, MBBS, MD Kathleen Ayers, PsyD
Mental Health Triage Algorithm for use by Non-Mental Health Providers in Acute Settings Peter Yellowlees, MBBS, MD Kathleen Ayers, PsyD Types of Patients 1. Chronically mentally ill/homeless and impoverished
More informationEmergency Care 3/9/15. Multimedia Directory. Topics. Emergency Care for Behavioral and. Psychiatric Emergencies CHAPTER
Emergency Care THIRTEENTH EDITION CHAPTER 23 Behavioral and Psychiatric Emergencies and Suicide Multimedia Directory Slide 42 Applications of Mechanical Restraints Video Topics Behavioral and Psychiatric
More informationKeep Calm and Carry On Management of the Agitated Patient in the ED 29TH ANNUAL UPDATE IN EMERGENCY MEDICINE FEBRUARY 21-24, 2016
Keep Calm and Carry On Management of the Agitated Patient in the ED 29TH ANNUAL UPDATE IN EMERGENCY MEDICINE FEBRUARY 21-24, 2016 Dr. Jeffrey Tyberg Sunnybrook Health Sciences Centre University of Toronto
More informationThe psychological disorders
The psychological disorders Defining abnormal Statistical infrequency Normal distribution; the normal curve Violation of norms Culture bound syndromes Personal distress Some disorders do not involve distress
More informationPsychosis & Antipsychotic Medications
Reality Non-reality VS. Psychosis & Antipsychotic Medications Disorganized thinking, hallucinations, delusions, bizarre behaviors What is Psychosis? Psychosis is mental disorganization to such a degree
More informationUsing the DSM-5 in the Differential Diagnosis of Depression
Using the DSM-5 in the Differential Diagnosis of Depression Wayne Bentham, MD Clinical Assistant Professor Department of Psychiatry and Behavioral Sciences University of Washington School of Medicine Depressive
More informationBRIEF PSYCHIATRIC RATING SCALE-ANCHORED (BPRS-A) BRIEF PSYCHIATRIC RATING SCALE-ANCHORED (BPRS-A):
BRIEF PSYCHIATRIC RATING SCALE-ANCHORED (BPRS-A): (Page 1 of 10) Date of (dd-mmm-yyyy): - - Time of (24 hour clock): : INSTRUCTIONS: Indicate the appropriate scale point for each item by marking X in the
More informationMoving from STIGMA to SUPPORT. Wendy Burch, NAMI-NYS Executive Director Shaniqua Jackson, NAMI-NYS Programs Coordinator
Moving from STIGMA to SUPPORT Wendy Burch, NAMI-NYS Executive Director Shaniqua Jackson, NAMI-NYS Programs Coordinator ! What is NAMI?! Overview of mental illness! De-escalation techniques and additional
More informationCrisis Management. Crisis Management Goals. Emotionally Disturbed Persons 10/29/2009
Crisis Management Crisis Management Goals try to ensure safety for yourself, other officers, subjects, and other citizens establish and maintain control resolve the situation positively when appropriate,
More informationForty-Eighth Annual Teaching Conference Pediatrics for the Practitioner -UT Health Science Center San Antonio School of Medicine June 10-12, 2011
Adelaide Robb, MD Associate Professor Psychiatry and Pediatrics Source Advisory Board Disclosure Speaker s Bureau Bristol Myers Squibb Yes Yes Yes Epocrates Research Contract Royalties Yes Stock Janssen
More informationChapter 9 The Mental Status Examination
Chapter 9 The Mental Status Examination Rick Grieve, Ph.D. PSY 442 Western Kentucky University Chapter Orientation The mental status examination (MSE) has held a revered place in psychiatry and medicine.
More informationAssessment of Competence Restoration: Determining the Threshold
University of Massachusetts Medical School escholarship@umms Psychiatry Publications and Presentations Psychiatry 5-2013 Assessment of Competence Restoration: Determining the Threshold Andrea L. Dinsmore
More informationDepression Management
Depression Management Ulka Agarwal, M.D. Adjunct Psychiatrist Pine Rest Christian Mental Health Disclosures The presenter and all planners of this education activity do not have a financial/arrangement
More informationAre All Older Adults Depressed? Common Mental Health Disorders in Older Adults
Are All Older Adults Depressed? Common Mental Health Disorders in Older Adults Cherie Simpson, PhD, APRN, CNS-BC Myth vs Fact All old people get depressed. Depression in late life is more enduring and
More informationMENTAL HEALTH A1 ASSESSMENT OF CURRENT PRESENTATION
BINDING MARGIN DO NOT WRITE AHS: FACILITY: SERVICE UNIT: PLEASE PRINT CLEARLY PH 608 SURNAME MRN GIVEN NAME DOB SEX ADDRESS WARD/SERVICE UNIT Assessment completed date: / / Time: : Place: Preferred language:
More informationSofia P. Simotas, Ph.D., PLLC 2524 Nottingham St. Houston, Texas 77005
Sofia P. Simotas, Ph.D., PLLC 2524 Nottingham St. Houston, Texas 77005 INTAKE FORM Name: Date: Gender: Female Male Date of birth: Address: Home phone: Cell: Okay to leave a message? Yes No Email: Emergency
More informationCOUPLE COUNSELING ASSESSMENT
COUPLE COUNSELING ASSESSMENT Date: Client 1 information: Name: Gender: Male Female Age - Date of Birth: Driver s License #: Email: Preferred Please Circle: Self-Pay or Insurance Client 2 information: Name:
More information8 Distinguishing Features of Primary Psychosis Versus Cannabis-Induced Psychosis
8 Distinguishing Features of Primary Psychosis Versus Cannabis-Induced Psychosis Ruby S. Grewal, MD and Tony P. George, MD, FRCPC As cannabis consumption rises, there has been significant emerging evidence
More informationAnnouncements. The final Aplia gauntlet: Final Exam is May 14, 3:30 pm Still more experiments going up daily! Enhanced Grade-query Tool+
The final Aplia gauntlet: Announcements Chapter 12 Aplia due tonight Chapter 13 Aplia due Wednesday Final Exam is May 14, 3:30 pm Still more experiments going up daily! Enhanced Grade-query Tool+ Now includes
More informationAdult Behavioral Health. Regional Meetings Spring 2017
Adult Behavioral Health Regional Meetings Spring 2017 TRIGGERS IN MEDICAL SETTINGS Invasive Procedures Removal of clothing Physical Touch Personal questions that may be embarrassing/distressing Power
More informationEXODUS HOMES RESIDENT APPLICATION
EXODUS HOMES RESIDENT APPLICATION ADMISSION DATE: RELEASE DATE: OPUS #: APPROVED APPLICANT NOTIFIED DENIED APPLICANT NOTIFIED NAME: ADDRESS: CITY: STATE ZIP CODE HAVE YOU EVER BEEN A RESIDENT OF CATAWBA,
More informationAffective Disorders most often should be viewed in conjunction with other physical and mental impairments.
THESE ARE THE FORMS I USE THIS IS NOT LEGAL ADVICE AND INTENDED TO SUPPLEMENT YOUR PARTICULAR FACTUAL SITUATION ONLY It is crucial you educate yourself on the Social Security Regulations that define and
More informationAnnouncements. Grade Query Tool+ PsychPortal. Final Exam Wed May 9, 1-3 pm
Grade Query Tool+ Announcements This tool is the definitive source for your final grade! Now includes Grade Estimator Tool PsychPortal Technical glitches in Learning Curves for Chapters 5, 14, and 15 are
More informationPsychiatric Residential Treatment Facility Referral
Psychiatric Residential Treatment Facility Referral Psychiatric residential treatment facility (PRTF) referral information Date of referral: Referral contact: Phone number: Referring facility or agency:
More informationDate of Onset is defined as the first day the claimant meets the definition of disability as defined in the Act and regulations.
THESE ARE THE FORMS I USE THIS IS NOT LEGAL ADVICE AND INTENDED TO SUPPLEMENT YOUR PARTICULAR FACTUAL SITUATION ONLY It is crucial you educate yourself on the Social Security Regulations that define and
More information