Historical Information Provided By Family Member Or Other Concerned Party - El Dorado County

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El Dorado County
Health System
Historical Information Provided by Family Member or Other Concerned 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. Behavioral Health staff will place this
form in the consumer/client’s mental health chart. Under California and Federal law, consumers have the right to view
their charts. 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 Section 5328(b)). This form was
developed originally by San Mateo County BHRS (and adapted by El Dorado County Health and Human Services Agency
Mental Health Division and NAMI of El Dorado County), behavioral health consumers/clients and health providers in order
to provide a means for family members and other interested parties to communicate the client’s behavioral health history
to hospitals/outpatient staff or 911 responders.
Today’s Date: ___________________ Name of Person Submitting This:
Relationship to Consumer/Client:
Consumer/Client Information
Name _________________________________________________________ Date of Birth
Phone ________________________ Address
Primary Language _________________________________ Religion
Medi-Cal:
Yes
No
Medicare:
Yes
No
Name of Private Medical Insurer
Yes
No
Please ask the consumer/client to sign an authorization permitting El Dorado County Behavioral Health
& Recovery Services providers to communicate with me about his/her care.
Yes
No
I wish to be contacted as soon as possible in case of emergency, transfer and discharge.
Yes
No
Consumer/Client has a Wellness Recovery Action Plan (WRAP) or Advance Directive.
(If yes, and a copy is available please attach a copy to this form.)
Brief history of mental illness (age of onset, prior 5150s, prior hospitalizations, history of unstable living situations, if
applicable -- attach additional pages if necessary)
Age symptoms or illness began:
Prior 5150’s?
Yes
No
If yes, when/where?
Prior hospitalizations?
Yes
No
If yes, when/where?
Does client have a conservator?
Yes
No
Don’t know
If yes, name:
Phone:
Page 1 of 4
Updated 6-2-2014

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