OCD Institute for Children and Adolescents (OCDI Jr.) Patient Referral Form Instructions

Transcription

1 OCD Institute for Children and Adolescents (OCDI Jr.) Patient Referral Form Instructions 1. Before you begin your application, you must download this PDF form to your computer. (Any information entered prior to downloading will not be saved.) 2. Open the downloaded form using Adobe Reader or other PDF software. 3. Fill out the application. (Remember to save as you go!) 4. When finished, click save. 5. Print out the form. 6. Submit the form by fax to , Attn: OCDI Jr. Admissions. Or by postal mail to: McLean Hospital SouthEast OCD Institute for Children and Adolescents, Attn: OCDI Jr. Admissions 23 Isaac Street Middleborough, MA Please contact OCDI Jr. Admissions at or with any questions. Parent/guardian names: Phone: Child name: Date completed: Child DOB: Mailing address: Referral source/contact info: Current level of care (e.g., inpatient, intensive outpatient, outpatient): Past inpatient hospitalization? If yes, indicate how many stays and length for each: Referral issues: Page 1 of 13

2 Has your child been given any psychological diagnoses? If so, which one(s)? Past treatment and response: Please indicate level of care (e.g., intensive outpatient, partial hospitalization, outpatient, group) and duration of treatment. Hs your child had exposure and response prevention (ERP) therapy? If so, please describe. Medical Information Medical problems: Height: Weight: Allergies: Page 2 of 13

3 History of suicide or self-injury? If yes, please provide information about number of attempts, if hospitalized, and extent of injury: History of substance abuse? If yes, please provide details: History of psychosis? If yes, please provide details: History of aggression toward others? If yes, please provide details: School Information Currently in school? Current difficulties in school: Homeschooled? On IEP/504? Insurance Information Can family self-pay? Page 3 of 13

4 OCDI Jr. Patient Referral Form Insurance Verification Form: Partial and Residential Date: Requesting Program: OCDI Jr Fax#: Patient Name: DOB: MRN, if in Epic: Address: Phone: City/State: Zip: Primary Insurance: Phone: Insurance ID#: Group# (if applicable): Subscriber Name: Subscriber DOB: Secondary Insurance: Phone: Insurance ID#: Group# (if applicable): Subscriber Name: Subscriber DOB: Office Use Only: Instructions: Please complete this form for patients who are likely admissions or scheduled partial patients. Fax to Patient Financial Services at throughout the day, preferably by 2pm each day. To be completed by PFS and faxed back to program: Is pre-certification required? **Carve-out information: Phone: Other information PFS received: **NOTE: As of 8/1/2018, if you set up your residential cases as pending pre-admission, PFS will enter coverage information into Epic, including carve-out name. Page 4 of 13

5 Obsessive Compulsive Checklist Patient Rating Scale Patient s Name: Date: Parent Completing the Form: My child s current treatment (please check whatever is applicable): Behavior Therapy Cognitive Therapy Medication Other Each section below contains several thoughts or behaviors your child may have experienced recently. For each symptom, mark yes or no based on whether he/she has had it in the past week. Then rate the combined severity of all symptoms in one box on the scale below. Severity refers to the average amount of frequency and distress that has occurred during the past week. Example Forbidden or perverse sexual thoughts or images. Forbidden or perverse sexual impulses about others. Obsessions about homosexuality. Sexual obsessions that involve children or incest. Obsessions about aggressive sexual behavior toward others. Please look at the example above. This person indicated having obsessions about homosexuality and aggressive sexual behavior toward others by checking yes for those symptoms. When the severity of the two symptoms was rated combined as very severe (referring to frequency and distress) by marking 10 on the rating scale. Page 5 of 13

6 Fear of acting on an impulse to harm self (e.g., cutting, stabbing). Fear of acting on an impulse to harm others (e.g., stabbing a friend). Fear of violent or horrific images in his/her mind. Fear of blurting out obscenities or insults. Fear of stealing things. Fear of being responsible for something else terrible happening (e.g., fire, burglary). Fear of harming others because of not being careful enough (other than by contamination, e.g., dropping a banana peel that somebody could slip on). Concern or disgust with bodily waste or secretions (e.g., urine, feces, saliva). Fear of dirt or germs. Excessive fear of environmental contaminants (e.g., asbestos, radiation, toxic waste). Excessive fear of household chemicals (e.g., cleaners, solvents). Disgust of animals or insects because they might carry diseases. Being bothered by sticky substances or residues. Concern that he/she will get ill because of contamination. Concern that he/she will get others ill because of contamination. Page 6 of 13

7 Forbidden or perverse sexual thoughts or images. Forbidden or perverse sexual impulses about others. Obsessions about homosexuality. Sexual obsessions that involve children or incest. Obsessions about aggressive sexual behavior toward others. Fear of losing or forgetting important information when throwing out something. Unable to decide whether to keep or discard things. Concern with religions, religious objects, sacrilege, and/or blasphemy. Excessive concern with right/wrong or morality. Concern with symmetry or exactness. Page 7 of 13

8 Concern with a need to know or remember. Fear of losing things. Superstitious ideas about lucky/unlucky numbers. Superstitious ideas about certain colors. Other superstitious ideas. If you checked yes for any symptoms in the box on the left, please mark the overall severity of these Concern with getting a physical illness or disease not by contamination (e.g., cancer). Washing hands excessively or in a ritualized way. Excessive showering, bathing, toothbrushing, grooming, or toilet routines. Cleaning household items or other inanimate objects excessively. Doing other things to prevent or remove contact with If you checked yes for any symptoms in the box on the left, please mark the overall severity of these Page 8 of 13

9 Praying to prevent harm. If yes, please indicate: to prevent harm to self to prevent harm to prevent terrible consequences Mental review of events to prevent harm. If yes, please indicate: to prevent harm to self to prevent harm to others to prevent terrible consequences Mental rituals (other than checking/counting) to prevent harm. If yes, please indicate: to prevent harm to self to prevent harm to others to prevent terrible consequences Checking behavior that he/she did not/will not harm others. Checking behavior that he/she did not/will not harm self. Checking behavior that nothing terrible happened. Checking behavior that he/she did not make a mistake. Checking some aspects of his/her physical condition or body. Page 9 of 13

10 Rereading or rewriting things. Repeating routine activities other than washing/checking (e.g., going in or out doors, getting up or down from chairs). Counting compulsions. Hoarding/collecting which results in significant clutter in the home. Putting things in order or arranging things until it feels right. Page 10 of 13

11 Need to touch, tap, or rub. Rituals involving blinking and staring. Telling, asking, or confessing to obtain reassurance. Superstitious behaviors (e.g., knocking on wood, wearing certain colors, stepping between cracks). Page 11 of 13

12 Depression/Risk Questionnaire 1. To your knowledge, on a 0-10 scale with 0 being none and 10 being very much, how depressed does your child currently feel? 2. Has your child had any recent losses? 3. Has your child had any recent relationship problems? 4. Do you believe your child has sufficient family and/or social support? 5. Is your family having significant financial problems with your living situation? 6. Is your family having significant financial problems that your child finds stressful? 7. Does your child currently have any thoughts of suicide? 8. Does your child have any plans to act on his/her thoughts of suicide? 9. Has your child ever made a suicide attempt? If yes, when and how? Page 12 of 13

13 10. Does your child have any history of threats of harm to others? 11. Has your child ever acted aggressively to others? 12. Does your child have trouble sleeping? How many hours of sleep does your child get per night? 13. Has your child had any recent changes in his/her appetite? Any recent weight loss/gain? How much? 14. Does your child feel hopeless? Please fax the completed form to OCDI Jr. at , Attn: OCDI Jr. Admissions. Or submit by postal mail to: McLean Hospital SouthEast OCD Institute for Children and Adolescents, Attn: OCDI Jr. Admissions 23 Isaac Street Middleborough, MA Please contact OCDI Jr. Admissions at or with any questions. Page 13 of 13