Form Fa-18 Pre-Admission Screening Resident Review (Pasrr) Level 1 Identification Screening Page 2
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42A. Psychiatric Treatment (Identify treatment dates within the last two years. Omit outpatient treatment.)
Inpatient Psychiatric Treatment (in psychiatric facility or hospital psychiatric unit)—dates: ___________________________________
Partial Hospital/Day Treatment (participated in structured, outpatient group program)—dates: _______________________________
Other Treatment—specify (e.g., psychiatric consultations, group/individual therapy)—dates: _________________________________
2B. Intervention (Identify treatment dates of services that were provided to prevent hospitalization within the last two years.)
Supportive living due to MI—dates: _____________________________________________________________________________
Housing intervention due to MI—dates: __________________________________________________________________________
Legal intervention due to MI—dates: ____________________________________________________________________________
Suicide attempt—dates: ______________________________________________________________________________________
Other—specify: _______________________________________________________________________________________
Hewlett Packard Enterprise Use Only: Meets criteria for duration? No
Yes
In Sections 3A and 3B, check the appropriate box to identify issues/limitations due to MI that arose frequently (“F”), occasionally (“O”)
or never (“N”) in the last 6 months. If the issue or limitation has a medical basis (not related to MI), check the box in the “M” column.
3A. Interpersonal Functioning
3B. Concentration/Task Limitations
Issue
Limitation
F
O
N
M
F
O
N
M
Altercations
Serious difficulty completing age related tasks
Evictions
Serious loss of interest in things
Fear of strangers
Serious difficulty concentrating
Illogical comments
Numerous errors in tasks that recipient should
be physically capable of completing
Suicidal talk
Requires assistance with tasks that recipient
Social isolation/avoidance
should be physically capable of accomplishing
Excessive irritability
Other—specify:
Easily upset/anxious
Hallucinations
Serious communication difficulties
Other—specify:
Issues/Limitations Notes: __________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
3C. Adaptation Problems (Check the appropriate box to answer each question as related to recipient’s MI (not medical) condition.)
In the last 6 months, has the recipient had:
Yes
No
Mental health intervention due to increased symptoms?
Judicial intervention due to symptoms?
Increased symptoms due to adaptation difficulties?
Serious agitation/withdrawal due to adaptation difficulties?
Other significant adaptation problems? (specify below)
Adaptation Notes: ____________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
Hewlett Packard Enterprise se Only: Meets criteria for disability?
Yes
Meets criteria for SMI?
No
Yes
No
FA-18
Page 2 of 4
PASRR Level 1 Identification Screening - Please Print or Type
11/05/12
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