Attachment 1A - Riverside County Department of Mental Health

RIVERSIDE COUNTY MENTAL HEALTH PALN
ASSESSMENT / CARE PLAN: INITIAL
Type of Plan
Medi-Cal/RCHC (CARES)
DPSS (ACT)
Attachment 1A
Page 1 of 3
Initial Assessment Date:
Provider:
Provider #:
Provider Phone #:
33
Provide Fax #:
Consumer Name:
First
Last
Consumer DOB:
Gender:
Consumer SS#:
M
F
Medi-Cal Number:
Consumer’s Primary Language:
Type of Living Situation:
Consumer’s Ethnicity:
Group Home
Bio Parents
Foster Home
Relative Placement (Minors)
Shelter Home
SNF
Other
Independent Living
FFA (Private Foster Home)
Board & Care
IMD
Name of Residential Facility (if Applicable):
Date of Placement:
Consumer’s Current Address:
Consumer’s Phone Number(s):
Primary Care Physician:
Date of Last Physical Exam:
Diagnosis:
Axis I:
Secondary:
Axis II:
Axis III:
Axis IV:
(Specific Psychosocial Stressors)
/
Axis V:
Current
Highest in Past
Year
Presenting Problems/Clinical Symptomology:
Risk Assessment
Suicide Ideation:
Suicide Intent:
Homicidal Ideation:
Homicidal Intent:
None
None
None
None
Mild
Mild
Mild
Mild
Moderate
Moderate
Moderate
Moderate
Severe
Severe
Severe
Severe
If any at present, describe type and frequency of ideation, plan, and means:
Send Form to Appropriate Unit: Community Access, Referral, Evaluation, & Support (CARES) – P. O. Box 7549, Riverside, CA 92513, Fax: (951) 358-5352
Assessment and Consultation Team (ACT), P.O. Box 7549, Riverside, CA 92513, Fax: (951) 687-5819
Confidential patient information. See California Welfare and Institutions Code Section 5328
February 2012
RIVERSIDE COUNTY MENTAL HEALTH PALN
ASSESSMENT / CARE PLAN: INITIAL
CONSUMER NAME: _______________________________________
Attachment 1A
Page 2 of 3
SOCIAL SECURITY #: ___________________________________
Recommendations (Reasons for continued treatment/expected duration of treatment):
Current Medication(s) and Dosage(s):
Prescribing MD:
History of Mental Illness in Family:
No
Prior Psychiatric Hospitalization(s)?
Mental Status
No
Yes
Yes
If yes, describe
If yes, where, when, and why:
Appearance
Orientation
Mood
Affect
Intelligence
Memory
Attention
Psychomotor
Judgment
Insight
Speech
Thought
Delusions
Clean
Oriented
Normal
Appropriate
Average
Intact
WNL
WNL
Good
Good
WNL
WNL
Somatic
Well Groomed
Disoriented
Anxious
Inappropriate
Above Average
Impaired
Short
Agitated
Fair
Fair
Pressured
Concrete
Jealous
Disheveled
Time
Depressed
Flat
Below Average
short Term
Impaired
Lethargic
Limited
Limited
Minimal
Disorganized
Grandiose
Bizarre
Place
Angry
Labile
Hallucinations
Auditory
Visual
Tactile
Olfactory
Long Term
Preservative
Retarded
Poor
Poor
Rambling
Ruminative
Persecutory
Person
Sad
Blunted
Situation
Euphoric
Depressed
Catatonic
Circumstantial
Paranoid
Erotic
Loose
Command
Occupation:
School: Education Level:
Drug / Alcohol Use:
Functioning / Grades:
Present
Past
Duration of current Remission:
Describe (Type, Amount, Frequency):
Drug Rehabilitation Treatment:
Dysfunction Rating:
February 2012
None
Mild
Moderate
Severe
Send Form to Appropriate Unit
Community Access, Referral, Evaluation, & Support (CARES) – P. O. Box 7549, Riverside, CA 92513, Fax: (951) 358-5352
Assessment and Consultation Team (ACT), P.O. Box 7549, Riverside, CA 92513, Fax: (951) 687-5819
Confidential patient information. See California Welfare and Institutions Code Section 5328
Tangential
RIVERSIDE COUNTY MENTAL HEALTH PALN
ASSESSMENT / CARE PLAN: INITIAL
CONSUMER NAME:
______________________________________
Attachment 1A
Page 3 of 3
SOCIAL SECURITY #: _____________________________
MEDICAL NECESSITY: Describe specifically how symptoms impair a specific area of functioning; ie: work, school, health/safety,
social. (For children there must be a reasonable probability/risk of significant deterioration in an important area of life functioning).
USE CURRENT DSM CRITERIA WHEN POSSIBLE:
GOALS: Must be related to the specific impairment(s) listed above. Must be measurable/observable, and must include current
frequency of the behavior, and the desired frequency.
Behavior Outcome/Goal # 1:
Target Date to Meet Goal #1:
Behavior Outcome/Goal # 2:
Target Date to Meet Goal #2:
Provider Intervention
Consumer Will:
\
PROPOSED TREATMENT: ** For providers requesting authorization through CARES only.
Refer for Psychiatric Services:
Yes
No If yes need to complete a “Provider Referral Request Form”
Individual Therapy:
session(s) per wk / month / qtr for
wks/ months ( 15/ 30 / 60 / 90 mins)
Group Psychotherapy:
session(s) per week / month
weeks / months
Family Therapy:
session(s) per wk / month / qtr for
weeks / months ( 30 / 60 minutes)
Family Collateral:
session(s) per wk / month / qtr for
weeks / months ( 30 / 60 minutes)
With:
Purpose:
Non Family Collateral:
session(s) per
With:
wk /
month /
qtr for
weeks /
months (
30 /
60 minutes)
Purpose:
Outpatient Consultation with:
Purpose:
Consumer requested a copy of Care Plan?
Interpretation Services Offered?
Yes
Yes
No
Consumer’s Response to Interpretation Services:
No
Date:
Consumer received copy of Care Plan?
Yes
No
Date
______________________________________________________________________
Contractor’s Signature and License
Date
Clinical Supervisor’s Signature and License
Date
Consumer’s Signature
Date
Parent/Guardian’s Signature
Date
Consumer Received Riverside County’s Informing Material
February 2012
Send Form to Appropriate Unit
Community Access, Referral, Evaluation, & Support (CARES) – P. O. Box 7549, Riverside, CA 92513, Fax: (951) 358-5352
Assessment and Consultation Team (ACT), P.O. Box 7549, Riverside, CA 92513, Fax: (951) 687-5819
Confidential patient information. See California Welfare and Institutions Code Section 5328