Adult Psychiatric Clinical Service Form Page 3
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4*Homicidal? q YES q NO If yes, how is this reflective of Mental illness vs. maladaptive social behavior? ____
__________________________________________________________________________________________
Is there duty to warn? ________________________________________________________________________
_____________________________________________________________________________________
Describe any history of attempts; history of violence towards others (include dates of events): _______________
__________________________________________________________________________________________
*Psychosis: q YES q NO If yes, describe delusions, hallucinations, command hallucinations, thought
disorders. Date of first episode? Neurological workup and date? ______________________________________
__________________________________________________________________________________________
Baseline (include any suicidality, parasuicidality or self-injurious behavior at baseline): ______________________
__________________________________________________________________________________________
*Other relevant information (Behavioral concerns, co-morbid conditions, etc.) ____________________________
__________________________________________________________________________________________
* Diagnostic and Statistical Manual (DSM) 5 Diagnoses (Mental Health and Medical)-DSM:
__________________
__________________________________________________________________________________________
Primary DX: ________________________________________________________________________________
__________________________________________________________________________________________
Comorbidities: ______________________________________________________________________________
__________________________________________________________________________________________
*Urine Drug Screen (UDS) & Blood Alcohol (BAL) results: _____________________________________________
__________________________________________________________________________________________
Treatment History: __________________________________________________________________________
__________________________________________________________________________________________
*Treatment plan (including specific symptoms): ____________________________________________________
__________________________________________________________________________________________
*Medications: ______________________________________________________________________________
__________________________________________________________________________________________
*Medication adherence? Barriers to non-adherence? ________________________________________________
__________________________________________________________________________________________
This facsimile contains privileged and confidential information intended only for the use of the specific individual or entity named above. If you or
your employer are not the intended recipient of this facsimile (or an agent responsible for delivering it to the intended recipient), you are hereby
notified that, any unauthorized distribution or copying of this facsimile for the information contained in it, is strictly prohibited. If you have received
this facsimile in error, please immediately notify the person named above by telephone and return the original facsimile to the above address via
the U.S. Postal Service. Thank You.
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