Brief Jail Mental Health Screen
ADVERTISEMENT
1
2B
J
M
H
S
RIEF
AIL
ENTAL
EALTH
CREEN
Section 1
AM
Name:
Detainee #:
Time:
__________________________________
___________________
Date:
/
/
___ ___
___ ___
___ ___ ___ ___
PM
First
MI
Last
Section 2
Questions
No
Yes
General Comments
1. Do you currently believe that someone can
control your mind by putting thoughts into
your head or taking thoughts out of your head?
2. Do you currently feel that other people know
your thoughts and can read your mind?
3. Have you currently lost or gained as much as
two pounds a week for several weeks without
even trying?
4. Have you or your family or friends noticed that
you are currently much more active than you
usually are?
5. Do you currently feel like you have to talk or
move more slowly than you usually do?
6. Have there currently been a few weeks when
you felt like you were useless or sinful?
7. Are you currently taking any medication
prescribed for you by a physician for any
emotional or mental health problems?
8. Have you ever been in a hospital for emotional
or mental health problems?
Section 3 (Optional)
Officer’s Comments/Impressions (check all that apply):
Language barrier
Under the influence of drugs/alcohol
Non-cooperative
_______________________________________________
Difficulty understanding questions
Other, specify:
Referral Instructions: This detainee should be referred for further mental health evaluation if he/she answered:
YES to item 7; OR
YES to item 8; OR
YES to at least 2 of items 1 through 6; OR
If you feel it is necessary for any other reason
Not Referred
Referred on
to ___________________________
___ ___ / ___ ___ / ___ ___ ___ ___
Person completing screen _______________________________________________
INSTRUCTIONS ON REVERSE
2005 Policy Reseach Associates, Inc.
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical