Download Mental Health/Substance Abuse History

Mental Health/Substance Abuse Outpatient Treatment Review Form
Fax: 312-324-0649 |UM Department Phone: 888-211-6851
Member: _________________________ Provider Name: __________________________ Provider Telephone: ___________________
Member DOB: _____________________ Provider Group/Clinic: _____________________ Provider Fax: _________________________
Member ID:_______________________ Service Address: __________________________ City/State/Zip: ________________________
Provider ID/NPI: ________________________________________ Tax ID# __________________________________________________
Mental Health/Substance Abuse History
Yes
No Previous Mental Health or Substance Abuse treatment inpatient/outpatient:
Level of care:
Dates Tx:
Level of care:
Dates Tx:
Level of care:
Dates Tx:
Yes No Drug/Alcohol Use (For Past 12 Months) If YES complete the following:
Substance
Amount
Frequency
For Current Substance Abuse Treatment:
Attended AA/NA? YES NO Linked to a Sponsor
Yes
Age Began
Last Used
No
TOXICOLOGY
Date
NEG
POS
Substance
Notes
Toxicology Substance: ALC: Alcohol; AMP: Amphetamine: BAR: Barbiturates: BEZ: Benzodiazepine: COC: Cocaine;
MET: Methadone; Opiate OPI: Opiates; PCP; PM: Prescription Medication: SUB: Suboxone: THC: THC
Current Signs/Symptoms (please check box if currently present):
Generalized Anxiety
Depressed Mood
Appetite Disturbance
Sleep Disturbance
Low Energy
Agitation
Labile
Irritability
Pressured Speech
Weight Loss/Gain
Panic Attacks
Phobias
Obsessions/Compulsions
Circumstantial/Tangential
Sexual Dysfunction
Paranoid Ideation
Loose Associations
Psychomotor Retardation
Concentration/Attention Problems
Impulse Control Problems
Conduct Problems
Oppositional Behaviors
Acute Stress Disorder
Other:
Mental Status (please check box if present)
Oriented x3
Impaired Judgment
Impaired Memory
Delusions- Type:
Other Cognitive
Impairment:
Hallucinations- Type:
Mental Health –Chemical Dependency OTR Form
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Member: ______________________
ID#_______________________
Risk Assessment (please check NO if not present- if checked, please provide additional information)
Yes
Yes
Yes
Yes
Yes
Yes
No
SUICIDAL RISK:
Ideation
Intent
Plan
Means
Attempt
Medication Name/Dosage/Frequency:
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
HOMICIDAL RISK:
Ideation
Intent
Plan
Means
Attempt
Rx by: Psychiatrist
Yes
Yes
Yes
Yes
PCP
No
ABUSE RISK:
Verbal
Emotional
Physical
Sexual
Not applicable:
1.
2.
3.
Diagnosis (please include Mental Health (DSM-5 or ICD-10) and other applicable co-occurring diagnoses)
Axis I:
Psychosocial Stressors:
Treatment Plan
GOAL #
Progress/Lack of Progress on Goal:
Goal Status: __ Accomplished & Removed__ Continue__ Additional Progress Needed __ Revised –See New goal/objective
GOAL #
Progress/Lack of Progress on Goal:
Goal Status: __ Accomplished & Removed__ Continue__ Additional Progress Needed __ Revised –See New goal/objective
GOAL #
Progress/Lack of Progress on Goal:
Goal Status: __ Accomplished & Removed__ Continue__ Additional Progress Needed __ Revised –See New goal/objective
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Member: ______________________
ID#_______________________
Discharge criteria/Plan:
Number of sessions estimated to complete this episode of care:_________________
Treatment Request
Date of first visit for this episode of care: ____________
Number of sessions to date: ____________
Requested Start Date for this registration: ____________
Please indicate type(s) of service requested and frequency:
Initial Diagnostic Evaluation (90791) with Medical (90792)
Family Psychotherapy (45-50min) 90847
Indiv. Psychotherapy (45min) 90834
Group Psychotherapy (60-90min) 90853
Indiv. Psychotherapy (60min) 90837
Other: ________________________
Wkly
Wkly
Mthly
Mthly
Qrtly
Qrtly
Other: ______
Other:______
Clinician Signature: ______________________________________
Wkly
Wkly
Wkly
Mthly
Mthly
Mthly
Qrtly
Qrtly
Qrtly
Other: ______
Other: ______
Other: _____
Date: ______________________
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