Pre- Admission/Crisis Intervention Screening Form
Request for __ (Request for mental health eval-even if the person does not go into the hospital) __ Inpatient
__ (Request for Sandbeach, Crisis bed or Children’s Home place) ___ Crisis Residential
__ (Request for Services) __ Outpatient Request
__ (This can be checked in conjunction with #1 or used for a crisis intervention other than hospital request) ____ Crisis Intervention
___ (used if involved with crisis but an Agency like the jail is asking for CMH input) ____ Consult
Date __ (Date of service)___ Time of Request_ (When request is received from the crisis line or presents at CMH) ___ Location Code__ (On call code or from Grid)
Service Code_ (Inpatient=T1023_others from grid) ______Contact was: Face to face____ Telephone ______
Contact Start Time: _ (When you started intervention; either face to face or telephone) ______am/pm Contact End Time: _(Contact end time including completion
of paperwork and Access contact if applicable) __ am/pm Disposition Time _ (The time you made the decision to hospitalize. This has to be with in 3 hours. It is not the
end of the contact or the time you actually get someone in the hospital it is when you decide hospitalization is needed ___
Name ___ (Consumer Name) _________________ Case #__ CMH case # ______ DOB __/____/____ Age ______ Social Security # _______-______-_____
Address___________________________________________ City ____________________ State ________ Zip___________ Phone #_____-_____-________
County of Residence __(Where the client lives)________County of Liability _(County responsible for payment)_ Race ________ Vet Status __________
__ Medicaid: Health plan ________
____Medicare ___ Private Insurance; Type __________ Policy # ____________________ No Insurance _____
Education: C‫ ٱ‬darg rednu gnidnettA‫ ٱ‬noitacude ceps nI‫ ٱ‬margorp gniniart nI‫ ٱ‬loohcs nI‫ ٱ‬.D.E.G/.S.H /de .cepS .pmoC‫ ٱ‬S.H naht sseL pmoC‫ٱ‬ollege grad
Employment Status: crof krow evititepmoc ni toN‫ ٱ‬krow rof gnikool ,deyolpmenU‫ ٱ‬emit trap deyolpmE‫ ٱ‬emit lluf deyolpmE‫ٱ‬e ‫ٱ‬Retired from work
A/N‫ ٱ‬tnemyolpme detroppus nI‫ ٱ‬pohs krow deretlehS‫ٱ‬
Corrections Status: airt gnitiawA‫ ٱ‬noitcidsiruj rednu toN‫ ٱ‬noisivrepus truoC‫ ٱ‬retneC noitneteD elinevuJ‫ ٱ‬liaJ morf noitaborP‫ ٱ‬liaj nI‫ ٱ‬nosirp nI‫ٱ‬l
nosirp morf eloraP‫ ٱ‬dekoob/tserra morf detreviD‫ ٱ‬dekoob dna tserrA‫ ٱ‬truoc yb derrefer roniM‫ ٱ‬gnicnetnes gnitiawA‫ٱ‬
Residential Living Arrangement: etavirP‫ٱ‬margorp ecnednepedni detroppuS‫ٱ‬retnec.ted elinevuj ,liaj nosirP‫ٱ‬residence w/parents‫ٱ‬Private residence on own
gnissiM‫ٱ‬sselemoH‫ٱ‬emoH gnisruN‫ٱ‬emoH .seR lareneG‫ٱ‬emoH laitnediseR dezilaicepS‫ٱ‬emoh ylimaf retsoF‫ٱ‬
Place of Contact _ (Where the person is seen)_CMH status: Open Case __ Closed Case __ Pending Case _ (may be awaiting a decision) _
New Case _ (first time call/intervention) ________
CMH CSM/Therapist Name: _ (Primary Worker assigned to case) ________ Psychotropic Meds prescribed by:__ (Psychiatrist or Primary Care Physician)
_____________
Current Meds and Dosage: ___ (list meds) _____________________________________________________________________________________________
Referral Source: ‫ٱ‬Family ‫ٱ‬Hospital ‫ٱ‬Police ‫ٱ‬Other_________Address:__ (Where did the request originate from? Also need to ask consumer if they would like us to
follow up with referral source. If so need release) ____________________________________________________________
Primary Care Physician: _____ (Name) _____________________ Address: _ (Complete address./ Need to complete co-ordination of care letter).
Assessment/ Precipitating Factors/ Intervention/Plan/Disposition:
_ As much as possible list what happened during the crisis intervention. INCLUDING THE PRECIPITATING FACTORS. Also note that additional information
can be recorded in different spots on the backside of form. _________________________________________________________
Substance Abuse History: (Need to address this issue with all consumers)
1.
Alcohol Use: ‫ٱ‬Yes ‫ٱ‬No How much? ___________________________ How Long? __________________________
2.
Drug Use: ‫ٱ‬Yes ‫ٱ‬No
3.
When Last Used? _____________________________________________
4.
Substance Abuse Treatment: ‫ٱ‬Yes ‫ ٱ‬No
Drug of Choice:________________________ How much?___________________________ How long?________________
When ? ______________________________ Where ?________________________________
Accommodation needs: __ (Does the consumer need any accommodations for service? Language, wheelchair, interpreter, etc..) _________________
Preliminary Diagnosis: (All Axis need to be addressed. Including 5th digit if appropriate)
Axis I: __________________________________ Axis II: _________________________ Axis III:__________________ Axis IV: Problems with: Primary support
group/Social environment/Education Occupation/Housing/Economic/Access to Health Care Services/Legal/Other Axis V: ________________
Severity of Illness
1: Severe/serious
2: Moderate
3: Mild
4: Not applicable
(Instructions: Mark the number relating to the level of severity criteria the individual meets under each category.
Write supporting clinical documentation including symptoms, functional impairments and risk potential in the Clinical Documentation Section.
Level of Severity
Severity of Illness: Documentation
All of this data will come from the protocol guidelines as provided .
1.Psychiatric
Reminder: If you list a consumer as Severe/serious that should follow the criteria explained under the section labeled “Inpatient”
If you list the severity of illness as Moderate the documentation should fit within the criteria as outlined as “crisis residential”t
If you list the severity of illness as mild it could be behaviors listed in the “crisis bed section” or not be to the levels explained
in Severe or Moderate.
Symptoms
2.Disruption of Self
Care Abilities
3.Possibility of Harm
to Self
Remember consumers that are evaluated as Moderate and appropriate for crisis residential must be open consumers in order to
be placed in Sandbeach or Jones Place. If consumer has private insurance, contact MI director or designee for approval prior to
getting auth.
4.Possibility of Harm
to Others
5.Possibility of Medication/
Drug Compliance or
Regimen Complication
Intensity of Services Required/ Disposition:
Inpatient
Crisis Residential
Other Community Support
Disposition/ Service Recommendations
A. Continuous medical supervision
and observation are necessary.
B. Requires highly structured
supervised care.
C. Meets criteria for Crisis Bed.
This is the section where you identify what the outcome
was and the intensity is identified. This must be all
A. Continuous skilled medical
observations needed due to
unmanageable side effects of
psychotropic medications
B. Consistent observation and
supervision of behavior is needed.
C. Appropriate for MI Outpatient Services
in one section. For example you can not circle one
Intensity from Inpatient and another from Crisis res.
A. Continuous observation and
control of behavior is needed to
protect individual, others, and/or
property.
B. Individual has reached a level of
clinical stability-but continues to
require a structured and supervised 24
hour program to consolidate progress.
C. Appropriate for referral to other
community services
A. A comprehensive multimodel
therapy plan is needed requiring
close medical supervision and
coordination.
B. Intensive monitoring of medication
regimen and response is necessary.
B. Individual needs to be temporarily
separated from natural environment.
at risk of further deterioration of condition.
B. A comprehensive, intensive program of
treatments, services and supports is needed.
Inpatient: ‫ٱ‬Formal Adult Voluntary ‫ ٱ‬Involuntary Admission (Petition=involuntary) Access Worker:_________
Service Authorized:___________ Authorization #____________Duration:____________Substance Abuse Referral:___________
Crisis line number provided:__Y/N____Referred elsewhere:______Where:______________ Appeal rights explained/Given:‫ٱ‬Yes ‫ٱ‬No Client Initials_____
.
Release of information: oN‫ ٱ‬seY‫ ٱ‬A/N‫ ٱ‬Co-ordination of Care: ‫ٱ‬Yes ‫ٱ‬No A/N ‫ٱ‬
___________________________________________________________________Cc: Hospital Liaison, Outpatient Receptionist, Outpatient Supervisor, Billing
Signature
Credentials
Date
MI Services Director, Access Center, Original to Chart.
REV:1/2014 mc