MH – Community Treatment Order Report
REPORT FOR THE MENTAL HEALTH REVIEW TRIBUNAL Patient Name: [text default=""] Date of Birth: [text default=""] Patient Address: [textarea default=""] -- Mental Health Facility/Health Care Agency -- [textarea default=""] -- Patient's legal status -- [checkbox value="Ambulatory - Community Treatment Order|Ambulatory - Voluntary"] [textarea default="Current CTO Expires on DATE"] -- Current diagnosis and background to current presentation -- The patient has an established diagnosis of: [checkbox value="Neurodevelopmental Disorder|Schizophrenia Spectrum Disorder|Bipolar Disorder|Depressive Disorder|Anxiety Disorder|Obsessive-Compulsive Disorder|Trauma and Stress Related Disorder|Dissociative Disorder|Somatic Complaint Disorder|Feeding and Eating disorder|Elimination Disorder|Sleep-wake Disorder|Sexual Dysfunction|Conduct Disorder|Substance Abuse Disorder|Neuro-Cognitive Disorder|Personality Disorder|Paraphilic Disorder"]. The patient's illness is characterised by: [checkbox value="overactive, aggressive, disruptive or agitated behaviour|non-accidental self-injury|problem drinking or drug-taking|cognitive problems|physical illness or disability problems|problems associated with hallucinations and delusions|problems with depressed mood|phobias|anxiety|obsessive-compulsive disturbance|stress|dissociative experiences|somatoform concerns|eating difficulties|sleep disturbance|sexual dysfunction|problems with relationships|problems with activities of daily living|problems with living conditions|problems with occupation and activities"] [textarea default=""] The most recent episode of care was precipitated by: [textarea default=""], in the context of [textarea default=""]. -- Efficacy of current CTO (if on an existing CTO) -- [checkbox name="CTO" value="Not applicable|Efficacy of current CTO:"][conditional field="CTO" condition="(CTO).is('Efficacy of current CTO:')"] [checkbox value="reduced patient's relapse frequency|reduced hospital admission frequency|provided a least restrictive option to hospitalization|enhanced symptom stability|increased treatment engagement|reduced risks in the community|enhanced social functioning|reduced police contact|improved physical health and wellbeing|enhanced quality of life|improved carer satisfaction|increased patient disatisafaction towards our service|increased patient feeling coerced and unfairly controlled|improved treatment compliance|enhanced objective quality of life|reduced contact with legal justice system|maintained stable housing|maintained employment|enhanced subjective quality of life|maintained engagement with health services"][/conditional] -- History of illness (including co-morbid conditions) and treatment as a patient or under previous community treatment orders -- Initial psychiatric presentation was: [textarea default="Name of illness on DATE"] Symptoms of the illness at this time were: [checkbox value="overactive, aggressive, disruptive or agitated behaviour|non-accidental self-injury|problem drinking or drug-taking|cognitive problems|physical illness or disability problems|problems associated with hallucinations and delusions|problems with depressed mood|phobias|anxiety|obsessive-compulsive disturbance|stress|dissociative experiences|somatoform concerns|eating difficulties|sleep disturbance|sexual dysfunction|problems with relationships|problems with activities of daily living|problems with living conditions|problems with occupation and activities"]. This [select value="resulted|did not result"] in a hospital admission at that time. There have been [textarea default="NUMBER"] incidents of illness relapse since this date. Co-morbid conditions include: [textarea default=""]. This illness has [select value="resulted|not resulted"] in significant psychosocial difficulties: [checkbox name="Q1" value="Education and literacy:"][conditional field="Q1" condition="(Q1).is('Education and literacy:')"] [checkbox name="education" value="Z55.0 Illiteracy and low-level literacy|Z55.1 Schooling unavailable and unattainable|Z55.2 Failed examinations|Z55.3 Underachievement in school|Z55.4 Educational maladjustment and discord with teachers and classmates|Z55.8 Other problems related to education and literacy|Z55.9 Problem related to education and literacy, unspecified"][textarea cols=80 rows=5 default="No further details provided by the patient."][/conditional] [checkbox name="Q2" value="Employment:"][conditional field="Q2" condition="(Q2).is('Employment:')"] [checkbox name="employment" value="Z56.0 Unemployment, unspecified|Z56.1 Change of job|Z56.2 Threat of job loss|Z56.3 Stressful work schedule|Z56.4 Discord with boss and workmates|Z56.5 Difficult conditions at work|Z56.6 Other physical and mental strain related to work|Z56.7 Other and unspecified problems related to employment"][textarea cols=80 rows=5 default="No further details provided by the patient."][/conditional] [checkbox name="Q5" value="Housing and economic circumstances:"][conditional field="Q5" condition="(Q5).is('Housing and economic circumstances:')"] [checkbox value="Z59.0 Homelessness|Z59.1 Inadequate housing|Z59.2 Discord with neighbours, lodgers and landlord|Z59.3 Problems related to living in residential institution|Z59.4 Lack of adequate food|Z59.5 Extreme poverty|Z59.6 Low income|Z59.7 Insufficient social insurance and welfare support|Z59.8 Other problems related to housing and economic circumstances|Z59.9 Problem related to housing and economic circumstances, unspecified"][textarea cols=80 rows=5 default="No further details provided by the patient."][/conditional] [checkbox name="Q7" value="The social environment:"][conditional field="Q7" condition="(Q7).is('The social environment:')"] [checkbox value="Z60.0 Problems of adjustment to life-cycle transitions|Z60.1 Atypical parenting situation|Z60.2 Living alone|Z60.3 Acculturation difficulty|Z60.4 Social exclusion and rejection|Z60.5 Target of perceived adverse discrimination and persecution|Z60.8 Other problems related to social environment|Z60.9 Problem related to social environment, unspecified"][textarea cols=80 rows=5 default="No further details provided by the patient."][/conditional] [checkbox name="Q11" value="The primary support group:"][conditional field="Q11" condition="(Q11).is('The primary support group:')"] [checkbox value="Z63.0 Problems in relationship with spouse or partner|Z63.1 Problems in relationship with parents and in-laws|Z63.2 Inadequate family support|Z63.3 Absence of family member|Z63.4 Disappearance and death of family member|Z63.6 Dependent relative needing care at home|Z63.7 Other stressful life events affecting family and household|Z63.8 Other specified problems related to primary support group|Z63.9 Problem related to primary support group, unspecified"][textarea cols=80 rows=5 default="No further details provided by the patient."][/conditional] [checkbox name="Q12" value="Certain psychosocial circumstances:"][conditional field="Q12" condition="(Q12).is('Certain psychosocial circumstances:')"] [checkbox value="Z64.0 Problems related to unwanted pregnancy|Z64.1 Problems related to multiparity|Z64.2 Seeking and accepting physical, nutritional and chemical interventions known to be hazardous and harmful|Z64.3 Seeking and accepting behavioural and psychological interventions known to be hazardous and harmful|Z64.4 Discord with counselors"][textarea cols=80 rows=5 default="No further details provided by the patient."][/conditional] Pt has been treated with: [textarea default="medication|referral to support services|psychoeducation|housing support|psychological services|suicide counselling|legal support|case management"] Pts adherence and compliance has been: [textarea default="good|fair|poor"] Patients motivation to treat illness has been: [select value="pre-contemplative|contemplative|preparatory|positively taking action"] Treatment effectiveness to date has been [select value="positive|fair|mixed|highly variable|poor"] [checkbox name="impac" value="Factors impacting on recovery:"] [conditional field="impac" condition="(impac).is('Factors impacting on recovery:')"] [checkbox value="precontemplative stage of motivation|denies the mental health diagnosis|personality factors|coping skills deficits|is difficult to form rapport with|has unrealistic expectations for recovery|has unrealistic expectations for mental health services|poor adjustment to mental health concerns|unpleasant side effects from medication|poor compliance with medication|is unreliable with scheduled appointments|routinely fails to respond to service contact requests|avoids service contact|is not hopefully about the future|does not desire change|is unwilling to play an active role in recovery|identifies with the sick role|has poor executive control|does not derive much benefit from their treatment|is socially isolated|lacks family support|continues to abuse substances|feels stigmatized by their mental health diagnosis|engages in splitting behaviours|is negative towards this mental health services|shy and inhibited temperament|overwhelmed by symptoms associated with mental health diagnosis|poor cohesion between services supporting patient|complicated by medical problems|a history of childhood adversity|complicated by multiple co-occurring mental health concerns|executive function difficulties|intellectual difficulties|tends to exaggerate concerns|receives secondary gains from current mental health status and functioning|has poor rapport with the author"] [textarea cols=80 rows=5 default=""][/conditional] [checkbox name="prosu" value="Factors promoting mental health recovery:"][conditional field="prosu" condition="(prosu).is('Factors promoting mental health recovery:')"] [checkbox value="treatment responsiveness|connectedness to individuals, family, community, and social institutions|problem-solving skills|coping skills|ability to adapt to change|sense of purpose or meaning in life Cultural, religious, or personal beliefs that discourage self-injury|good social skills|ability to manage feelings of anger|good health|access to mental and physical health care|healthy fear of risky behaviours and pain|hope for the future and optimism|sobriety|medical compliance|sense of the importance of health and wellness|impulse control|strong sense of self-worth or self-esteem|sense of personal control or determination|access to a variety of clinical interventions|help seeking behaviours|resiliency|expressed reasons for living|being married|being a parent|strong relationships, particularly with family members|opportunities to participate in and contribute to school or community projects and activities|living in a reasonably safe and stable environment|sense of responsibility and duty to others|being a pet owner|intolerant attitude towards deviant behaviour|above average intelligence|having good academic grades|having a positive social orientation|having highly developed social skills|having the ability to plan ahead|having realistic expectations for the future|being religious|being connected to family|being connected to supportive adults outside their immediate family|ability to discuss problems with others|sharing activities with friends and family|having the consistent presence of a parent|involvement in pro-social activities|having positive role models|having affective relationships which are strong, close and prosocially oriented|being committed to learning and self improvement|being committed to work|having high needs for achievement|having non-deviant peers|having peer groups that do not condone antisocial behaviour|involvement in pro-social activities|exposure to positive parenting practices"][/conditional]. -- Length of order proposed and why-- [textarea default="I am applying for a X month CTO to better manage illness, in the least restrictive way"] -- How the CTO will benefit the patient as the least restrictive form of safe and effective care -- [checkbox value="reduce patient's relapse frequency|reduce hospital admission frequency|provide a least restrictive option to hospitalization|enhance symptom stability|increase treatment engagement|reduce risks in the community|enhance social functioning|reduce police contact|improve physical health and wellbeing|enhance quality of life|improve carer satisfaction|improve treatment compliance|enhance objective quality of life|enhance subjective quality of life|offer patient access to community support services|provide access to mental health reviews and psychiatric services"] -- Current medication and any changes during the period of the order -- [textarea default="Current medication is"] -- Plans and goals for the person’s ongoing care and future treatment and management -- [checkbox name="Acute" value="Acute care:"][conditional field="Acute" condition="(Acute).is('Acute care:')"] The primary goal is the short term reduction in severity of symptoms and/or personal distress associated with the recent onset or exacerbation of a psychiatric disorder.[/conditional] [checkbox name="Funct" value="Functional gain:"][conditional field="Funct" condition="(Funct).is('Functional gain:')"] The primary goal is to improve personal, social or occupational functioning or promote psychosocial adaptation in a consumer with impairment arising from a psychiatric disorder.[/conditional] [checkbox name="Inten" value="Intensive extended:"][conditional field="Inten" condition="(Inten).is('Intensive extended:')"] The primary goal is prevention or minimisation of further deterioration, and reduction of risk of harm in a consumer who has a stable pattern of severe symptoms, frequent relapses or severe inability to function independently and is judged to require care over an indefinite period.[/conditional] [checkbox name="Cons" value="Consolidating gain:"][conditional field="Cons" condition="(Cons).is('Consolidating gain:')"] The primary goal is to maintain the level of functioning, or improving functioning during a period of recovery, minimise deterioration or prevent relapse where the consumer has stabilised and functions relatively independently. Consolidating gain may also be known as maintenance. [/conditional] -- The patient’s response to treatment and willingness to continue with treatment -- At our last contact I would rate the severity of [text default="the patient's"] illness as [select value="stable and without symptoms|fully recovered|mildly ill|moderately ill|severely ill|among the most extremely ill patients"]. Compared to their condition on admission, I rate [text default="the patient's"] progress as: [select value="very much improved|much improved|minimally improved|no change|minimally worse|much worse|very much worse|unable to be assessed"]. When asked to rate their progress, [text default="the patient"] reported [select value="very much improved|much improved|minimally improved|no change|minimally worse|much worse|very much worse|not sure"]. when asked about willingness to continue with treatment, [text default="the patient"] reportedly was [select value="very willing|ambivalent|against any further treatment"]. -- The patient’s attitude towards the application and confirmation that contents of the report have been discussed with the person -- [textarea default="The patient is against / agreeable to the application, and I confirm that the contents of the report have been discussed with the patient"] -- Psycho social issues, including family and community supports -- Identified psychosocial issues include [checkbox value="difficulty with initiating and responding to conversation|withdraw from social contact|difficulty showing warmth to others|grooming and self-care|wearing clean and appropriate clothes|neglect of physcal health|violence towards others|making and keep friendships|maintaining an adequate and healthy diet|generally look after and taking medication without reminding|unwilling to take medications whn prescribed by a doctor|uncooperative with mental health services|has problems living with others in a household|behaving offensively|behaving irresponsibly|incapable of work"] Family supports include: [textarea default=""] Community supports include: [textarea default=""] -- Viewpoint of family and carers to CTO and their role or input into discharge planning ( if relevant) -- [textarea default="Family / Carer do / not support CTO"] Clinician name: [text default=""] Position: [text default=""] Contact number: [text default=""] signed and dated
There are 82 form elements.