Approved for use with South Country Members / 05/2016V1
South Country Health Alliance
2300 2300 Park Drive, Suite 100
Owatonna, MN 55060.
Phone (866) 722-7770
Fax (507) 431-6329
Date of Interview:
Member Demographics
Member Name:
Member PMI:
Member DOB/Age:
Member Address:
Member City, State, Zip:
List Mental Health Diagnosis with ICD 10 Code:
1.
2.
3.
4.
5.
(Please attach WHODAS 2.0 or include version used and score)
Presenting Symptoms
Anxious Guilty feelings Weight loss Sexual issues
Ashamed Heavy feeling Difficulty breathing Sleep problems
Unable to enjoy self Hopelessness Dizziness Wound up
Depressed/Sad Irritable/angry/lose temper Headaches Discomfort
Elevated mood Loneliness Heart racing Isolative
Excessive Worry Low self-esteem Increased appetite Withdrawn
Feel inferior Paranoia Weight gain Auditory hallucinations
Feel unworthy Tense feelings Low energy/tired Distressing memories
Feel numb Aches/pain Night terrors Disturbing thoughts
Frequent mood swings Decreased appetite Numbness/tingling Delusions
Poor concentration Racing thoughts Visual hallucinations Thoughts/urges of self-harm
Cry easily/often Impulsive Wants to die Wants to harm others
Lack motivation Reactive Repetitive actions Restless/fidgety
Shaking Violent Actions of self-harm
Reason for referral:
Member’s perception of his/her condition:
Duration of symptoms:
Potential consequences of symptoms:
Contributing contextual non-personal factors:
Cultural Influences and Client Impact:
Prognosis:
Current Life Situation
Current living situation:
Current Financial Status: / Highest Education Level Completed: / Employment Status:
Current Relationship Status:
Children/Step Children? YES NO If yes, how many? Ages?
Primary Care Physician: / Primary Care Clinic:
Any known allergies? YES NO / If yes, please list:
Current Medication / Dose / Start Date / Current Medication / Dose / Start Date
1. / 9.
2. / 10.
3. / 11.
4. / 12.
5. / 13.
6. / 14.
7. / 15
8. / 16.
Relevant History
Records Review:
Mental Health Treatment History:
Developmental History:
Maltreatment or Abuse History:
History of Drug/Alcohol Abuse:
Legal History:
Health History and Concerns:
Family History of Mental Illness and/or Substance Use Disorders:
Would you like services specific to language, age, gender, culture, religious preference, race, ethnicity, sexual orientation or disability? YES NO If yes, please specify:
Functional Impairment
Coping Skills / Ability to Care for Self
Daily Living Skills / Medical/Dental
Mental Health Services / Financial Management
Use of drugs/alcohol / Housing/Shelter
Education/School / Transportation
Employment / Danger to Self and/or Others
Social / Legal
Interpersonal/Relationship and Environment / Other:
Strengths and Resources; include extent and quality of social networks:
How does diagnosis interact with/impact member’s life?
Describe how diagnosis criteria is met, duration of symptoms and functional impairment:
Clinically Appropriate Services Needed
Dialectical Behavior Therapy (DBT)
Psychotherapy
Assertive Community Treatment (ACT)
Transportation Services
Intensive Residential Treatment (IRTS)
Adult Rehabilitative Mental Health Services (ARMHS) -if this is recommended, please select areas of skills which should be addressed below:
Communication Skills Budgeting/Financial
Community Integration Independent Living Skills
Community Support and Resources
Interpersonal Skills Training / MI/CD Groups / Treatment
County Case Management
Health Education/Medication Management/ Nursing Services
Housing Supports
Psychiatry/Medication Management
CPS Services
Crisis Services
Other Special Considerations
Identified Communication Needs:
None Reported
TDD/TTY Device
Language Interpreter Services needed
Other Spoken Language
Assisted Listening Device
Other: / Identified Barriers to Learning:
None Reported
Learning Disability/Type
Inability to read and/or write
Developmental Disability
Other:
Mental Status Exam
Appearance / Clean Neat Unkempt Disheveled Other:
Looks Stated Age / YES NO Older Younger
Eye Contact / Appropriate Inappropriate Other:
Orientation / Fully Oriented Time Place Person Situation
Memory / Normal Limits
Deficient: Immediate Recent Remote Other:
Attention / Adequate Inadequate Other:
Perception / Adequate Inadequate Other:
Motor Activity / Normal Slowed Restless Agitated Accelerated Other
Cognitive Performance / Normal limits Poor memory Low self-awareness Short attention
Developmental disability Poor concentration Impaired judgement
Slow processing Full Scale IQ is known:
Thought Process / Normal limits Accelerated Delusional Paranoid Ruminative
Intact Grandiose Tangential Loose association Slowed
Hallucination (visual, auditory, tactile)
Danger to Others / Does not appear dangerous to others Violent temper Threatens others
Physical Abuse Hostile Assaultive Homicidal ideation
Homicidal threats Homicide attempt
Danger to Self / Does not appear dangerous to self Suicidal ideation Recent attempt
Self-injurious/self-mutilation: Hx of attempt:
Current plan/means:
Sensory Deficits / None Speech Hearing Vision
Speech / Clear Slurring Slowed Loud Soft Pressured Minimal
Excessive Incoherent Delayed FastOther:
Mood / Euthymic Unremarkable Depressed Tearful Anxious Manic
Labile Other:
Affect / Normal Blunted Congruent Euphoric Incongruent Flat Expansive Labile Other:
Insight into Problem / Takes responsibility Intellectual insight Emotional insight
Slight awareness Blames others Complete denial
Judgement / Good Fair Poor
Impulse Control / Good Fair Poor
Attitude / Cooperative Guarded Withdrawn Uncooperative Oppositional
Belligerent /Hostile Apathetic Suspicious Other:
Additional observations and others involved in assessment:
Narrative:
According to the Comprehensive Mental Health Act, the mental health professional conducting this diagnostic assessment must complete the need for the following:
CAGE-AID / Completed / Score:
GAIN SS / Completed / Score:
PHQ-9 / Completed / Score:
CASII (For Children Over 6) / Completed / Score:
ECSII (For Children Under 6) / Completed / Score:
LOCUS / Completed / Score:
Serious and Persistent Mental Illness Definition
“ A person with a serious and persistent mental illness” means an adult who has a mental illness and meets at least one of the following criteria:
(1) The adult has undergone two or more episodes of inpatient care for a mental illness within the preceding 24 months;
(2) The adult has experienced a continuous psychiatric hospitalization or residential treatment exceeding six months’ duration within the preceding 12 months;
(3) The adult has been treated by a crisis team two or more times within the preceding 24 months;
(4) The adult (i) has a diagnosis of schizophrenia, bi-polar disorder, major depression, or borderline personality disorder; (ii) indicates a significant impairment in functioning; AND (iii) has a written opinion from a mental health professional, in the last three years, stating that the adult is reasonably likely to have future episodes requiring hospitalization or residential treatment, of a frequency described in clause (1) or (2), unless ongoing case management or community support services are provided; (5) The adult has, in the last three years, been committed by a court as a person who is mentally ill under chapter 253B, or the adult’s commitment has been stayed or continued; or
(6) The adult (i) was eligible under clauses (1) to (5) but the specified time period has expired or the adult was eligible as a child under section 245.4871, subdivision 6; and (ii) has a written opinion from a mental health professional, in the last three years, stating that the adult is reasonably likely to have future episodes requiring hospitalization or residential treatment, of a frequency described in clause (1) or (2), unless ongoing case management or community support services are provided.
If #4 or #6 is selected, written opinion must be provided here:
Severe Emotional Disturbance Definition
“ A person with a severe emotional disturbance” means a child who has anemotional disturbance and who meets one of the following criteria:
(1) The child has been admitted within the last three years or is at risk of being admitted to inpatient treatment or residential treatment for an emotional disturbance; or
(2) the child is a Minnesota resident and is receiving inpatient treatment or residential treatment for an emotional disturbance through the interstate compact; or
(3) the child has one of the following as determined by a mental health professional:
- Psychosis or a clinical depression; or
- Risk of harming self or others as a result of an emotional disturbance; or
- Psychopathological symptoms as a result of being a victim of physical or sexual abuse or of psychic trauma within the past year; or
If #4 is selected, written opinion must be provided here:
Clinician Information and Signature:
Mental Health Professional Signature: / Date:
Printed Name: / Agency Name and Address:
I am a qualified Mental Health Professional in the following field:
Psychiatric Nursing Psychology (LP, LPP) Clinical Social Work Psychiatry
Licensed Marriage & Family Therapy Allied Field:
Thank you!
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