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Home My WebLink AboutMental Health Screening315.02.01.001 (Form last updated 10/28/2016) 1 IDAHO DEPARTMENT OF CORRECTION Mental Health Screening Resident Name: IDOC #: DOB: Date of Report: Intake/New Arrival Inter Institutional Transfer Restrictive Housing Current Risk Factors1.Did the transporting officer report any concerns? If so please explain:No Immediately notify the shift commander2.Right now, do you have thoughts of hurting yourself?No 3. Do you have any immediate plans to hurt yourself?Describe:No 4.Right now, are you currently feeling hopeless about your future?No Refer to MH for follow up within 24 hrs 5. Right now, do you have any mental health symptoms or complaints?On a 1-10 scale with 1 being none at all and 10 being extremely serious; rate your symptoms.Describe symptoms:(If rated at “5” or above, refer for clinician follow-up) No 6.Within the past year have you engaged in self-harm or attempted suicide?Date: ___________Means/Method:_______________________Intent:______________________No Suicide/Self Harm History No Refer to MH for follow up within 72 hoursPrior Emergent Treatment7.Within the last 24 months, have you had a mental health hospitalization or been placed on amental health observation/watch in a correctional facility ?Date: __________ Hospital/Facility: _____________________ Reason: _______________________Date: __________ Hospital/Facility: _____________________ Reason: _______________________ No Medication9.Are you currently taking mental health medications?Name: ___________Dose/Freq:______Last dose: ______Pharm: _________Prescriber:__________Name: ___________Dose/Freq:______Last dose: ______Pharm: _________Prescriber:__________Name: ___________Dose/Freq:______Last dose: ______Pharm: _________Prescriber:__________ No 10. Have you ever taken mental health medications in the past?Name: ___________Dose/Freq:______Last dose: ______Pharm: _________Prescriber:__________Name: ___________Dose/Freq:______Last dose: ______Pharm: _________Prescriber:__________Name: ___________Dose/Freq:______Last dose: ______Pharm: _________Prescriber:__________ No No Follow up to occur within 14 days if indicated following clinician review. 8.Within the last 24 months, have you engaged in self-harm or attempted suicide? Date: ___________Means/Method: _______________________Intent:______________________ Date: ___________Means/Method: _______________________Intent:______________________ 11.Prior to 24 months ago, have you been hospitalized for mental health reasons? Date: __________ Hospital/Facility: _____________________Reason: _______________________ Date: __________ Hospital/Facility: _____________________Reason: _______________________ 12.Prior to 24 months ago, have you attempted suicide or engaged in self-harm? Date: ___________Means/Method: _______________________Intent:______________________ Date: ___________Means/Method: _______________________Intent:______________________ 13.Do you have a history of outpatient mental health treatment?Date: __________ Care Provider: _______________________Reason: _______________________Date: __________ Care Provider: _______________________Reason: _______________________Mental Health TreatmentNo Substance Use14.Have you ever used any type of substances:No What? First Used: Last Used: How Much? What? First Used: Last Used: How Much? 15.Is this your first time in prison? 16.Have any family members or significant persons in your life attempted or committed suicide? 17.Have you recently experienced a significant loss such as a death of a close family member or friend?No 18.Have you ever been arrested for a sex crime?No 19.Have you ever been a victim of sexual or physical abuse?No In custody: No Other contributing suicide risk factors 20.Have you had a head injury? Describe: No 21.Have you ever received special education services?No 22.Are you worried about something other than your current legal situation? Describe:No 23.Do you have a physical illness that is causing you distress or pain? Describe:No No In custody: No 2Current Mental Health Status (Check all that apply) Alert, oriented x _______ Disoriented Reports Hallucinations Endorses Delusions Grooming/ Hygiene Eye Contact Affect Mood Thought Process Speech Movement/Activity to situation to situation to situation to situation Angry Cheerful Calm to situation Logical Goal directed Disorganized topic to topic quickly to situation situation Aggressive DISPOSITIONAction Taken Initial Housing Recommendation Emergent/Urgent: Referred to the Shift Commander under Policy 315 Refer to Mental Health for follow up within 24 hours Refer to Mental Health for follow up within 72 hours Refer to Mental Health for follow up within 14 days if indicated following clinician review No need for Mental Health follow up - cleared Cleared for general housing placement Not cleared - referred for holding cell placement Other placement: __________________________________________________ __________________________________________________ Informed Consent I acknowledge that I have answered all questions truthfully and have been informed about how to obtain mental health services. I consent to routine mental health care provided by facility healthcare professionals. Resident Signature:_____________________________________________________Date: ___________________________ Screener/ Reviewer Screened by: ___________ __________ ______________________________ Date Time _________________________ Printed Name/Title Signature Screening Reviewed: _________ ________ __________________________ ______________________________ Date Time Printed Name/Title Clinician Signature MH Secondary Assessment Completed: ________ ________________________ _________________________ Date Printed Name/Title Signature Clinical Follow Up Follow Up SOAP Note/if indicated: ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ _____________ ____________ ___________________________ ________________________________ Date Time Printed Name/Title Clinician Signature Moving from 315.02.01.001 (Form last updated 10/28/2016) Mental Health Screening