Outpatient Treatment Report Form
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1
2OUTPATIENT TREATMENT REPORT
Mutual of Omaha
Directions: To request authorization of additional outpatient sessions, please fill out the information completely and fax to BHS Precertification at 402-351-2880. If you choose to mail this form,
send the completed form to the attention of BHS Precertification at Mutual of Omaha, Mutual of Omaha Plaza S3, Omaha, NE 68175.
DEMOGRAPHICS:
CURRENT DSM-IV DIAGNOSIS:
Case Number: _____________________________________________
AXIS 1: Primary:_____________ _______________________
_______________________
Patient Name: ________________________________ DOB: ___________
AXIS II: __
______________________________________________________________________
Insurer’s Name:_______________________ Record #_________________
AXIS III: _______
_______________________________________________________________
Practitioner’s Name/Licensure: ___________________________________
AXIS IV:
_______________________________________________________________________
Practitioner’s Phone: __________________ Fax: ___________________
AXIS V: Current:
Highest in past 12 months:
________________
_____________________
CURRENT SIGNS AND SYMPTOMS (Circle):
Active Alcohol/Substance Use
Anger/Aggression
CURRENT FUNCTIONING (Circle): None
Mild Moderate Severe
Delusion
Depressed Mood
Apathy
Decreased concentration/Inattention
Family/Marital Relationships
1
2
3
4
Weight/Appetite Change
Worthlessness
Job/School Performance
1
2
3
4
Anorexia/Bulimia
Helpless/Hopeless
Peer Relationships/Socialization
1
2
3
4
Fatigue/Decreased Energy
Agoraphobia/Phobia
Financial Situation
1
2
3
4
Irritability
Anxiety
Activities of Daily Living
1
2
3
4
Panic Attack
Dissociation
Obsessions/Compulsions
Hyperactivity
Explain categories rated moderate or severe:
______________________________________
Perpetrator of Abuse
Oppositional
_______________________________________________________________________________
Victim of abuse
Paranoia
_______________________________________________________________________________
Elevated Mood
Grief
Restlessness
Somatic Complaints
RISK ASSESSMENT (Circle):
Sexual Functioning
Rapid speech
Impulsivity
Hallucination
Suicidality:
None Ideation Plan Means Prior Attempt
When
: ____________
Sleep
Disturbed thought process/content
Homicidality:
None Ideation Plan Means Prior Attempt
When:
____________
Other:
Psychiatric Hospitalization in past: 3months 6 months 12 months Other
_________________________________________________
:____________
Other risk behaviors:
_________________________________________________________
MEDICATIONS:
TREATMENT PLAN:
Has patient been evaluated for medications?
Yes
No
Is patient on psychotropic medications?
Yes
No
Improved functioning/symptom reduction and discharge from treatment
_____
If yes, is patient compliant with medications?
Yes
No
Transfer to support groups or self-help and discharge from treatment
_____
Is patient seeing a psychiatrist/PCP regularly?
Yes
No
Provide ongoing supportive counseling and maintain stabilization of symptoms
_____
_____
Provide ongoing medication management
List current psychotropic medications with dosage/frequency/start date:
Other:
_____
_________________________________________________________________
1. _______________________________________________________
________________________________________________________________________________
2. _______________________________________________________
3. _______________________________________________________
st Revised 07/01/05 Page 1 of 2
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