(PC) to Specialty Behavioral Health (BH) Referral Form - Alameda ...

Primary Care (PC) to Specialty Behavioral Health (BH) Referral FormFax this referral to ACCESS at (510) 346-1083Include the HealthPAC Initial Risk Assessment and any other supporting documentsPatient Name:Primary Language:Date of Referral:Patient Date of Birth:HealthPAC ID#:Clinic ID or MR#:Referral to: Alameda County Behavioral Health Care Services - ACCESSPhone: (800) 491-9099Fax: (510) 346-1083Referral Source:Provider Name:Provider Title/Role:Referring Clinic Name:Referring Clinic Address (must include):Contact Phone:Fax # (required):Purpose of Referral (medication, therapy, etc.):ACCESS Final Disposition:Referred to:Phone Number:Type of Service:Number of Sessions Authorized:Fax Number:Level:Name of Staff Making Referral (Print)DatePhone NumberHealthPAC - Version from 3-9-121

PatientName:HealthPAC Initial Risk Assessment (to be completed face to face)1. Date of assessment:2. Demographics/Patient Contact Information:Social Security #: Male Female TransgenderAddress: City: Zip:Tel:Ethnicity/Race:Birthplace:Marital Status:Birth Last Name:Highest Educational Grade completed:Hispanic Origin:Mother's First Name:Preferred Language:Physical Disability:3. Presenting Behavioral Problems (check all that apply and/or describe below):Adjustment to trauma/major stressors, separation, loss, death, job, school Mania, elevated moodAnger ControlAnxiety, fear, panic, agitationDepression, hopelessnessEating DisturbanceEmployment/School functioning problemsFamily relationship problemsPain without clear medical explanationPsychosis, unreal thoughts or beliefs, auditory and/or visual hallucinationsResidential instability/Risk of homelessnessSleep DisturbanceSubstance abuse/dependenceVictim of abuse, physical, sexual and/or severe neglectHyperactivityImpulse control problemsOther, describe belowDESCRIBE ONSET, DURATION, AND SEVERITY OF SYMPTOMS/IMPAIRMENTS, INCLUDING RELEVANT HISTORY AND SIGNIFICANT LIFE EVENTS:4. Risk Assessment (check appropriate rating)Dangerto selfNoneHistory but norecent intent,ideation orfeasible planRecentideation, nocurrentfeasible planRecent ideation, intention,plan that is feasible and/orhistory of a potentially lethalattemptCurrent ideation or command hallucinations reself-harm, current intent, plan that isimmediately accessible and feasible, and/orhistory of multiple potentially lethal attempts.Call 911 IMMEDIATELY.DangertoothersNoneHistory but norecent gestureor ideationRecentideation, nocurrentfeasible planRecent homicidal ideation,physically harmful aggressionor dangerous fire setting, butnot in past 24 hours. Hasfeasible plan to harm othersAcute homicidal ideation with an accessible,feasible plan of physically harmful aggression,or command hallucinations involving harm ofothers. Or intentionally set fire that placedothers at significant risk of harm. Call 911IMMEDIATELY.HealthPAC - Version from 3-9-122

Name:HealthPAC Initial Risk Assessment (to be completed face to face)4A. Other Risk Factors (if yes, please describe below:)No Yes4B. Previous Psychiatric HospitalizationNo Yes Date/reason of last hosp:4C. Risk Assessment (ELABORATION OF ALL RISK FACTORS)5. Current Mental StatusMoodAffectThought process/contentHallucinationsOrientationCognitiveDepressedAppropriateNormalAuditoryTimeMemory problemAnxiousInappropriateLoose/TangentialVisualPersonLack of insightEuphoricGrandioseOtherPlacePoor judmentOtherParanoidConcrete thinkingMentalStatusComments:6. Substance Use Concerns (Describe screening done, current, and past use, and impact of use):HealthPAC - Version from 3-9-123

Name:HealthPAC Initial Risk Assessment (to be completed face to face)7. LegalIssuesCourt Mandated Treatment Probation/Parole: History of arrest:No Yes No Yes No Yes8. MentalHealthCurrently receiving servicesNo YesIf yes, where:ConservedNo YesHistory of treatmentNo YesCurrent psych medsNo YesIf yes, add to medication list9. Primary Careworking mental healthdiagnos(es):10. AdditionalComments (describefunctional impairments,primary care treatmentattempts, and response,other factors):Please answer #11 and #12 below OR provide other documents listing current medications and health conditions:11. Current Medications (include allbehavioral and physical meds)Med Allergies:Medication Name Strength Frequency Purpose Prescriber12. Patient's otherhealth conditions:Staff Name (print):Clinician/Staff/Other Appropriate SignatureDate:HealthPAC - Version from 3-9-124