Inpatient Treatment Report Form
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1
2INPATIENT TREATMENT REPORT (ITR) - Page One of Two
Requested Start Date for this Authorization ____/____/____
Current Impairments: Scale 0=none, 1=mild, 2=moderate, 3=severe, na=not assessed
0 1 2 3 na Mood Disturbance (Depression or mania)
Level of Care:
Inpatient
23 hr
CSU
Partial
RTC
IOP/SOP
0 1 2 3 na Anxiety
Group Home
Halfway House
Other __________________________
0 1 2 3 na Psychosis
0 1 2 3 na Thinking/Cognition/Memory
Type of Review:
Prospective
Concurrent
Discharge
Retrospective
0 1 2 3 na Impulsive/Reckless/Aggressive
Type of Care:
Mental Health
Substance Abuse
Detox
0 1 2 3 na Activities of Daily Living
Precipitating Event: __________________________________________________
0 1 2 3 na Weight Change Assoc. w/Behav Dx
Gain
Loss
na of ______
____________________________________________________________________
0 1 2 3 na Medical/Physical Condition(s)
pounds in last three months
____________________________________________________________________
0 1 2 3 na Substance Abuse/Dependent
Current weight - ______ lbs
na
0 1 2 3 na Job/School Performance
Height - ______ft. _____ in.
na
Patient’s Current Location:
ER
Jail/Detention
Facility
0 1 2 3 na Social/Marital/Family Problems
Provider’s Office
Home/Community
0 1 2 3 na Legal
Demographics:
Mental Health/Psychiatric Treatment History: (Please check all that apply)
None
Patient’s Name ___________________________________Date of Birth: _________
Outpatient. If “Outpatient” is checked, please indicate:
Unknown
Patient/Policyholder ID#: __________________________ Tel #: _______________
Outcome:
Unknown
Improved
No Change
Worse
Patient’s City/State: ___________________________________________________
Treatment compliance (non-med):
Unknown
Poor
Fair
Good
Subscriber’s Employer/Benefit Plan: ______________________________________
IOP/Partial. If “IOP/Partial” is checked, please indicate:
Facility: _________________________________________ Fac: ID#____________
Outcome:
Unknown
Improved
No Change
Worse
Fac. Address/City/St: __________________________________________________
Treatment compliance (non-med):
Unknown
Poor
Fair
Good
Attending Provider: _______________________________ Tel #:_______________
Inpatient/Residential/Group Home: If “Inpatient/Residential” is checked, please indicate:
UR Name: ___________________________________________________________
Outcome:
Unknown
Improved
No Change
Worse
UR Phone #: ____________________________ UR Fax #: ____________________
Treatment compliance (non-med):
Unknown
Poor
Fair
Good
Number of psychiatric hospitalizations in the past 12 months: _________________
DSM-IV Diagnosis:
Substance Abuse Treatment History: (Please check all that apply)
None
Unknown
Axis I
1) __________________________ 2)______________________________
Outpatient. If “Outpatient” is checked, please indicate:
Axis II: 1)__________________________ 2)______________________________
Outcome:
Unknown
Improved
No Change
Worse
Treatment compliance (non-med):
Unknown
Poor
Fair
Good
Axis III: 1)__________________________ 2)______________________________
IOP/Partial. If “IOP/Partial” is checked, please indicate:
Axis IV: ____________________________________________________________
Axis V: Current GAF: ______________ Highest GAF prev. year:______________
Outcome:
Unknown
Improved
No Change
Worse
Treatment compliance (non-med):
Unknown
Poor
Fair
Good
Current Risks: Risk Level Scale: 0=none, 1-mild, ideation only; 2=moderate, ideation
Inpatient/Residential/Group Home: If “Inpatient/Residential” is checked, please indicate:
with EITHER plan or history of attempts; 3=severe, ideation AND plan, with either
Outcome:
Unknown
Improved
No Change
Worse
intent or means; na=not assessed. Circle risk level for each category and check all
Treatment compliance (non-med):
Unknown
Poor
Fair
Good
boxes that apply:
Number of substance abuse hospitalizations in the past 12 months” _____________
Risk to Self (SI):
0 1 2 3 na
with
ideation
intent
plan
means
Other Treatment History:
Risk to Others (HI): 0 1 2 3 na
with
ideation
intent
plan
means
Mandatory workplace referral?
Yes
No EAP involved:
Yes
No
Current serious attempts:
Yes
No Circle SI HI
EAP Name: _________________________________________________________________
Prior serious attempts:
Yes
No Circle SI HI
Criminal justice involvement in the last 12 months?
Yes
No
Prior serious gestures:
Yes
No Circle SI HI
Currently on probation:
Yes
No
Date of the most recent attempt or gesture: ____/____/____
History of sexually inappropriate/aggressive behavior?
Yes
No
History of fire setting in the last 12 mos?
Yes
No
Active gang involvement in the last 12 mos?
Yes
No
DSS/CPS involvement in the last 12 mos?
Yes
No
ValueOptions 2005 Rev. 08.20.07
Victim of sexual or physical abuse?
Yes
No
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