Instructions: This form is to be completed, signed, and dated on all patients who are being referred for psychiatric commitment and disposition. Time of Call: _______:_________ Date of Call: _____/_____/______ Patient Name:__________________________________________ Sex: Male Female Birth Date:______/______/_______ Social Security #: _________/__________/___________ Ethnicity/Culture: African American Caucasian Asian American Hispanic Other: __________________ Language Preference: English Spanish Creole Chinese Other:______________ Hearing-Impaired: Yes No Interpreter Needed: Yes No Out of State: Yes No State: ________________ County of Residence: Kent New Castle Sussex Medicaid #: _____________ Insurance: Aetna BC/BS Carve-out Cigna Coventry Diamond State Partners DPCI Medicare None Tri-care Other:______________ DSAMH Provider: Connections Horizon House FHR PSI NCCMH / 809 Hudson Center GMHC KMHC None Other: _______________ Was Provider notified: Yes No Contact Person: ________________________ Veteran: Yes No Presentation to ER: Self Family Police CCCP VA Ambulance Other: _____________ Time of Arrival @ ER:_____:_____A.M. P.M. Source of Information/ Facility: ______________ Contact # ____________________________________ Presenting Complaint (History of presenting problem, participating factors, and current systems): _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ Recent Stressors: Relationship Family Job Housing Financial Legal Other: ______________________ Health Issues: IDDM NIDDM Hypertension Cardiac HIV Status Hepatitis C Other: __________________________ Special Needs: Wheelchair Oxygen Crutches Cane Walker Other:______________________ Describe:_______________________________________________________________________________________ Danger to Self Danger to Others Current Level of Functioning Suicidal Thoughts Yes No Homicidal Thought/ Violence Yes No Any difficulty in the following areas: Suicidal Attempt Yes No Past History of Violence/Aggression Yes No Sleeping Yes No Past History of Gestures/Attempts Yes No Access to Weapons Yes No Eating Yes No Current Plan Yes No Current Plan Yes No Going to Work/School Yes No Did they act on Plan Yes No Verbal Threats Yes No Personal Hygiene Yes No What stopped them? _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ ___________________ Physical Aggression Yes No Command Hallucinations to Harm Others Yes No Weight Gain Yes No Weight Loss Yes No Relationships Yes No Marital Status Yes No Hopelessness Yes No Command Hallucinations of Self-Harm Yes No Self-Mutilation Yes No Describe:_________________________ _________________________________ Describe: _____________________________________ _____________________________________ _____________________________________ _____________________________________ _____________________________________ __________________ Describe: _______________________________ _______________________________ _______________________________ _______________________________ _______________________________ _____________ Previous Psychiatric Treatment: Yes No Treating Psychiatrist: _______________________ Where/ Date: ________________________________ List all medication that the client is currently taking: ______________________________________________________________________________________ ______________________________________________________________________________________ Mental Status Assessment: Mood: Calm Anxious Depressed Manic Hostile Sad Irritable Anger Judgment: Intact Impaired Decreased Energy Labile Impulsiveness Psychotic Symptoms (Delusions, Paranoia) Describe: ________________________________________________________ History of Substance Abuse: Yes or No Opiates Cocaine Cannabis Benzos Amphetamines Alcohol __________ BAL/Breathalyzer UDS Other: _________________________________________________ Amount/Frequency: _____________________ Last Use: ____________________________ Withdrawal Symptoms: Describe (History of Seizures, Vital Signs) _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ List all Medications Administered in the ER. _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ Restraints Yes No Initial information taken by:________________________ Date: _______/_________/________ Form Completed by: ________________________________ Date: _______/_________/________