Behavioral Health Comprehensive Initial Assessment

Consultation Information
Patient Name:[text name="variable_1" default="sample text"]
Date of Birth:[text name="variable_1" default="sample text"]
Date of Referral: [date name="variable_1" default="08-08-2022"]
Date of Evaluation:[date name="variable_1" default="08-08-2022"]
Referring Clinician: [text name="variable_1" default="sample text"]
Referral Concerns: [textarea name="variable_1" default="*consider copying and pasting referral template here*"]
Collateral History:[checkbox name="variable_1" value="Chart Review|Psyckes|HIE|Other"][textarea name="variable_1" default="*specify your collateral sources*"]
Consent:[checkbox name="variable_1" value="Obtained|Declined|Deferred"][textarea name="variable_1" default="sample text"] [checkbox name="variable_1" value="We reviewed the rights and limits of confidentiality and the duty to warn and protect."] 

Chief Complaint:[textarea name="variable_1" default="patient's own words"]

HPI: [textarea name="variable_1" default="*one-liner describing the current medical and psychiatric situation/symptoms and burdens.*"]

On Assessment: [textarea name="variable_1" default="*describe patient's current presenting problem, stance, and symptoms and any interventions performed*"] 

Psychiatric History:
Current Mental Health Diagnoses: [textarea name="variable_1" default="sample text"][radio name="variable_1" value="None|Unknown|Unwilling to Discuss"]
Previous Mental Health Diagnoses:[textarea name="variable_1" default="sample text"][radio name="variable_1" value="None|Unknown|Unwilling to Discuss"]
Current Psychotropic Medications: [textarea name="variable_1" default="include all psychoactive medications including cannabis and opioids"][radio name="variable_1" value="None|Unknown|Unwilling to Discuss"]
Medication Adherence: [checkbox name="variable_1" value="Adherent|Intermittently Adherent|Non-adherent"][radio name="variable_1" value="N/A|Unknown|Unwilling to Discuss"]
Past Psychotropic Medication Trials:[textarea name="variable_1" default="sample text"][radio name="variable_1" value="None|Unknown|Unwilling to Discuss"]
Last Precriber: [textarea name="variable_1" default="name/number of clincian"][radio name="variable_1" value="None|Unknown|Unwilling to Discuss"]
Current Outpatient Treatment: [textarea name="variable_1" default="*name/number of clinician or clinic*"] [radio name="variable_1" value="None|Unknown|Unwilling to Discuss"]
Past Outpatient Treatment:[textarea name="variable_1" default="name/number of clinician or clinic"][radio name="variable_1" value="None|Unknown|Unwilling to Discuss"]
Past Inpatient treatment: [textarea name="variable_1" default="dates admitted and name of hospital, include SUD rehabs, partial hospitalizations and residential treatment here"][radio name="variable_1" value="None|Unknown|Unwilling to Discuss"]
Did the patient verbally agree to authorize release of information for Prospero-Health to contact previous mental health clinician?[radio name="variable_1" value="Yes|No|Undecided"]
Written authroization of release of infromation for mental health information to be obtained and placed in chart in subsequent visits as indicated. 

Psychiatric Review of Symptoms: 
[checklist name="psychiatric ROS was performed and was" value="negative for|positive for|per HPI, otherwise unremarkable"]
[select name="the following symptoms" value="depressed mood|hopelessness|helplessness|anhedonia|excessive guilt|irritability|difficult to control worry|panic attacks|ruminative thoughts|obsessions|compulsions|hypervigilance|hyperstartle|nightmares|dissociative symptoms|psychosis|delusions|mania|hypomania|impulsivity|inattention|disinhibition|memory impairment|"]

Substance Use History: [textarea name="variable_1" default="include current/past use and any screening tools"]

Family History: [textarea name="variable_1" default="*obtain family MH history including if any history of completed suicides*"]

Social History: [textarea name="variable_1" default="*born/raised, race/ethnicity, spiritual beliefs, family composition, living situation, highest education, occupation, previous incarceration or legal trouble, trauma screen"]

Risk Assessment: 
Current SI:[textarea name="variable_1" default="sample text"]*if yes complete CSSR-S*
Previous SI/SGA/NSSIB:[textarea name="variable_1" default="sample text"]
Current HI: [textarea name="variable_1" default="sample text"]
Previous VI/HI: [textarea name="variable_1" default="sample text"]
Does patient have access to firearms or other weapons: [textarea name="variable_1" default="sample text"]
Protective Factors: [select name="include" value="future oriented|problem solving skills|evidence of adaptive coping|engagement in work or school|strong social supports|community engagement|stable housing|willingness to engage with mental health providers|positive self-esteem|connection to spiritual beliefs|participation in cultural activities"]
Current level of risk: [radio name="of harm to self or others" value="low|moderate |high|imminent"]The patient is biologically and environmentally predisposed for mental health conditions and is at chronically elevated risk as compared to the general population.

Safety management plan: Should the patient become a danger to self or others, patient/family member/caregiver agree to call 911 and take the patient to the nearest emergency room. 

Mental Status Examination: [textarea name="variable_1" default="sample text"]

Assessment and Formulation: [textarea name="variable_1" default="include your diagnosis and differential/rule outs and a brief psychiatric formulation."]


Recommendations and Plan:[textarea name="variable_1" default="include your recommendations for management including psychotropic medications, labs, referrals etc."]

Disposition: 
[radio name="Based on clinical presentation the patient will be managed in the following episodes of care: (add only 1)" value="Consulting Evaluation with plan for primary NP/SW management and reconsultation as needed|Short term treatment within the Standard BH episode of care until stabilized|Longer term within the Complex BH episode of care until stabilized and connected to community resources for ongoing management"]

Signature: [textarea name="variable_1" default="sample text"]
Date:[date name="variable_1" default="08-08-2022"]


Consultation Information
Patient Name:
Date of Birth:
Date of Referral:
Date of Evaluation:
Referring Clinician:
Referral Concerns:
Collateral History:
Consent:

Chief Complaint:

HPI:

On Assessment:

Psychiatric History:
Current Mental Health Diagnoses:
Previous Mental Health Diagnoses:
Current Psychotropic Medications:
Medication Adherence:
Past Psychotropic Medication Trials:
Last Precriber:
Current Outpatient Treatment:
Past Outpatient Treatment:
Past Inpatient treatment:
Did the patient verbally agree to authorize release of information for Prospero-Health to contact previous mental health clinician?
Written authroization of release of infromation for mental health information to be obtained and placed in chart in subsequent visits as indicated.

Psychiatric Review of Symptoms:



Substance Use History:

Family History:

Social History:

Risk Assessment:
Current SI:*if yes complete CSSR-S*
Previous SI/SGA/NSSIB:
Current HI:
Previous VI/HI:
Does patient have access to firearms or other weapons:
Protective Factors:
Current level of risk: The patient is biologically and environmentally predisposed for mental health conditions and is at chronically elevated risk as compared to the general population.

Safety management plan: Should the patient become a danger to self or others, patient/family member/caregiver agree to call 911 and take the patient to the nearest emergency room.

Mental Status Examination:

Assessment and Formulation:


Recommendations and Plan:

Disposition:


Signature:
Date:


Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.43, 51 form elements, 202 boilerplate words, 3 text boxes, 26 text areas, 3 dates, 4 checkboxes, 1 check lists, 12 radio buttons, 2 drop downs, 60 total clicks
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