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"]