Outpatient Review Form printable pdf download

Outpatient Review

Current Impairments: (Please select/circle one value for each type of impairment)

Requested Start Date ____/____/____

Scale: 0=none 1=mild/mildly incapacitating 2=moderate/moderately incapacitating

3=severe or severely incapacitating na=not assessed

NOTE: This form cannot be used to request ECT or psychological testing



Mood Disturbance (Depression or Mania)

0 1 2 3 na



Anxiety

0 1 2 3 na

Type of Service Requested:

 Mental Health

 Substance Abuse



Psychosis/Hallucinations/Delusions

0 1 2 3 na

Patient Name: _______________________________________________________



Thinking/Cognition/Memory/Concentration Problems

0 1 2 3 na

Date of Birth: ___________________Age: ______________  M  F



Impulsive/Reckless/Aggressive Behavior

0 1 2 3 na



Activities of Daily Living Problems

0 1 2 3 na

Address (City/State only): ______________________________________________



Weight Change Associated with a Behavioral Diagnosis

0 1 2 3 na

Tel #: _____________________Patient’s Insurance ID#:______________________

Select One: Gain Loss na of _________ lbs. in last three months

Patient's Employer/Benefit Plan: _________________________________________

Current weight = _____ lbs. na Height = ________ft. ______ inches na



Medical/Physical Condition

0 1 2 3 na

Provider Name: ________________________________License _______________



Substance Abuse/Dependence

0 1 2 3 na

Name of Program/Clinic (if applicable): ___________________________________

Select all that apply: Alcohol Illegal Drugs Prescription Drugs



Job/School Performance Problems

0 1 2 3 na

VO Provider ID # (if known): ________________Tel #_______________________



Social/Relationship/Marital/Family Problems

0 1 2 3 na

Service Address: ______________________________________________________



Legal Problems

0 1 2 3 na

City/State/Zip: _______________________________________________________

 Is this also your mailing address?  Yes  No If not, please update below

Treatment Plan: Reason for continued treatment (please select primary reason)

signature.

 Remains symptomatic

 Prepare for discharge within coming month

 Are you independently licensed to provide services in the State where you are treat-

 Maintenance

 Facilitate return to work

ing this patient?  Yes  No

Please indicate type(s) of service provided BY YOU, and the frequency.

 ID #: _____________________ Check Which:

 SSN

 Tax ID

 NPI

 Medication Management M0064

Wkly Monthly Qtrly Other ______

 Indiv. Psychotherapy (30 min) 90832

Wkly Monthly Qtrly Other ______

Diagnosis:

 Indiv. Psychotherapy (45 min) 90834

Wkly Monthly Qtrly Other ______

 Behavioral DX

 Medical DX

(ICD code & description)

(ICD code & category)

 Family Psychotherapy (45-50 min) 90847 Wkly Monthly Qtrly Other ______

 Group Therapy (60-90 min) 90853

Wkly Monthly Qtrly Other ______

1. __________/____________________

1. ________/_____________________

 Other ___________________________

Wkly Monthly Qtrly Other ______

 Other ___________________________

Wkly Monthly Qtrly Other ______

2. __________/____________________

2. ________/_____________________

 Social Elements Impacting DX: 1. _______________

2. _______________

Please indicate type(s) of service provided BY OTHERS (select all that apply):

 Optional Functional Assessment: Tool: __________________ Score:____________

 Medication Management  Indiv. Psychotherapy

 Family Psychotherapy

Additional Info: ______________________________________________________

 Group Therapy

 Community Program(s)

 Self Help Group(s)

Are the Patient’s family/supports involved in treatment?  Yes

 No

Treatment History: (please select all that apply)

Has Patient been evaluated by a psychiatrist:

 Yes

 No

 Previous Treatment in the Past 12 Months, excluding current course of treatment:

Type: Mental Health  Substance Abuse  Both  None  Unknown

Current Psychotropic Medications: Dosage Frequency Usually adherent?

 Outpatient  Partial/IOP  Inpatient  Residential  Group Home  Other

1.  YES  NO

 Outcome:  Unknown  Improved  No Change  Worse

2.  YES  NO

 Treatment Compliance (Non-Med):  Unknown  Poor  Fair  Good

3.  YES  NO

 Is the individual currently receiving disability benefits  Yes  No

Treating Provider’s Signature: _________________________________Date: ___________

Current Risk Assessment:

(Please select/circle one value for each type of risk

Updated Mailing Address: ______________________________________________________

Key: 0 = none; 1 = mild, ideation only; 2 = moderate, ideation with EITHER plan or history of

City/State/Zip: _______________________________________________________

attempts; 3 = severe, ideation AND plan, with either intent or means; na = not assessed)

Patient’s risk to others:

Patient’s risk to self:

Page 1 of 2 ValueOptions revised 08/28/14

Outpatient Review Form

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