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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 1 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 2 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: ______________________ 3