Initial Psychiatric Assessment (Page 5 of 5) in pdf

NAME/MRN

Initial Treatment Plan/Targeted Case Management:

Does consumer meet the criteria for TCM? (May include moderate or above Functional Impairment and/or risk of losing

placement/housing, need for financial support, social support, prevocational/employment assistance, rehabilitation, AOD services, or

other programs or services considered necessary.)

Yes

Explain: _________________________________________________________________________________________________

________________________________________________________________________________________________________

Referral to Coordination of Care with:

PCP

Case Management

Therapist

Family/ Other Support

Substance Abuse Tx

Housing

Community Agencies

Vocational Rehab

Social Security

Details: _______________________________________________________________________________________

Labs Ordered: __________________________________________________________________________________

______________________________________________________________________________________________

Medications Prescribed / Dosage / Frequency:

______________________________________________________________________________________________

Drug Information Sheet for each medication was given to consumer and family.

Benefits/Risks/Possible adverse effects of medication and Alternatives to medication have been discussed.

An opportunity was given to ask questions.

The consumer and/or family appear to understand the information on the form.

If appropriate, discuss the interaction of psychiatric medication with the following: Pregnancy, Lactation,

Alcohol, Nutrition, and Non-Psychiatric Medications

An Informed Consent was signed within the past two years.

Consumer (Family) is able to manage own medication:

Yes

If not, explain:

_______________________________________________________________________________

Additional Information:

______________________________________________________________________________________________

MD/DO/NP Signature:

Date:

PRINT FULL NAME AND TITLE ____________________________________________________________________

Data Entry Clerk Initials

MHC113Initial Psychiatric Assessment (9/13)

Initial Psychiatric Assessment Page 5