Download Mental Health/Substance Abuse Outpatient Treatment Review Form

 Mental Health/Substance Abuse Outpatient Treatment Review Form Fax: 1-­‐844-­‐363-­‐6772 | UM Department Phone: 1-­‐844-­‐340-­‐2217 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 Age Began Last Used For Current Substance Abuse Treatment: Attended AA/NA? YES NO Linked to a Sponsor Yes 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 Pressured Speech Depressed Mood Weight Loss/Gain Appetite Disturbance Panic Attacks Sleep Disturbance Phobias Low Energy Obsessions/Compulsions Agitation Circumstantial/Tangential Labile Sexual Dysfunction Irritability Paranoid Ideation Mental Status (please check box if present) Oriented x3 Impaired Memory Impaired Judgment Other Cognitive Impairment: Loose Associations Psychomotor Retardation Concentration/Attention Problems Impulse Control Problems Conduct Problems Oppositional Behaviors Acute Stress Disorder Other: Delusions-­‐ Type: Hallucinations-­‐ Type: 1 Member: ______________________ ID#_______________________ Risk Assessment (please check NO if not present-­‐ if checked, please provide additional information) Yes No Yes No Yes No SUICIDAL RISK: HOMICIDAL RISK: ABUSE RISK: Yes Yes Yes Ideation Ideation Verbal Yes Yes Yes Intent Intent Emotional Yes Yes Yes Plan Plan Physical Yes Yes Yes Means Means Sexual Yes Attempt Yes Medication Name/Dosage/Frequency: Attempt Rx by: Psychiatrist PCP Not applicable:
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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 Wkly Mthly Qrtly Other: ______ Indiv. Psychotherapy (45min) 90834 Group Psychotherapy (60-­‐90min) 90853 Wkly Mthly Qrtly Other: ______ Wkly Mthly Qrtly Other: ______ Indiv. Psychotherapy (60min) 90837 Other: ________________________ Wkly Mthly Qrtly Other:______ Wkly Mthly Qrtly Other: _____ Clinician Signature: ______________________________________ Date: ______________________ 3