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Form Ab-1424 - Historical Information Provided By Family Member Or Other Interested Party

If available, this document should accompany

the 5150 to the receiving facility.

Alameda County Behavioral Health Care Services

Historical Information Provided by Family Member or Other Interested Party

California Assembly Bill 1424 (2001), now a law, requires all individuals making decisions about

involuntary treatment to consider information supplied by family members and other interested parties.

Mental health staff will place this form in the consumer’s mental health chart. Under California and

Federal law, consumers have theright to view their chart The Family member completing this form has

the right to withdraw consent to release information given by them and have the information regarded

as confidential {Welfare & Institutions Code 5328(b)}. This form was developed jointly by Alameda

County Behavioral Health Care Services, Alameda County Family Coalition, family members, mental

health consumers, mental health providers, patients’ rights advocates and the judicial system in order

to provide a means for family members and other interested parties to communicate the client’s mental

health history pursuant to AB 1424.

Name of Consumer __________________________ Date of Birth ____________ Phone _________

Address __________________________________________________________________________

Primary Language______________________________ Religion____________________________

Medi-Cal:

Yes

Medicare:

Yes

Name of Private Medical Insurer ______________________________________________________

Please ask the consumer to sign an authorization permitting Alameda County mental

Yes

health providers to communicate with me about his/her care.

I wish to be contacted as soon as possible in case of emergency, transfer or

Yes

discharge.

The consumer has a Wellness Recovery Action Plan (WRAP) or Advance Directive. (If

Yes

yes, and a copy is available, attach a copy to form.)

Brief History of mental illness (age of onset, prior 5150’s, prior hospitalizations, history of violence,

history of self harm, history of unstable living situations)(Attach additional pages, if necessary):

Age illness began ______________

Prior 5150’s?

Yes

If yes, how many _______________

Prior hospitalizations?

Yes

If yes, how many _______________

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AB 1424 form rev. 10/2006

Form Ab-1424 - Historical Information Provided By Family Member Or Other Interested Party