Name easeiv elem Page lole
Type ciisisseieening Medicaid-l smaslli Dale {0107/2015
5 < 

 

Name: JEFFUS, 
Type: Crisis Screening
Printed on esizsrzois at 12: 12 PM

 

Case#: 818?37
Medicaid#: 519286114

Page: 20M
Date: 1010749015

 

 

Affect: Appropriate Cl Labiie
Thought Content: Appropriate illogical
Mood 1] Appropriate 
Delusions: None Somatic
insight: El Adequate Dispiaced Blame
Haiiucinations: None [1 Auditory
Thoughts: Organized El Tangential
Orientation: Person Piace
Memory: intact l3 Recent
Appetite: Unchanged El increased
Steep: Unchanged Ci increased
Types of Substances used: <9 NA

Aicohoi, Last used:
Amphetamines: Last used:

Benzodiazepines: Last used:

Cannabis: Last used:
Cocaine: Last used:

Opiates: Last used:

Other: Last used:

Relevant Previous History Treatment:

0 Outpatient: Access

0 inpatient:

Current Physicat Concerns:

{Ii Denies any Medical Probiems
Current Medical Problems:
Ei Cancer El Diabetes [It HBP Cl Heart Problems
it Other, Enter Response

Current Medications:

Fiat

Concrete
i3 irritabie

Grandiose
Ci Little

Ci Visuai
Loose
Time

[It Remote

i3 Decreased

El Decreased

Frequency and Duration:
Frequency and Duration:

Frequency and Duration:

Frequency and Duration:
Frequency and Duration:
Frequency and Duration:

Frequency and Duration:

0 Denies previous treatment

E1 Siezures

{Final Approved on 10i1212015 at 11:08 

i3 Broad E3 NA
Broad Ci NA
l] Hostiie El NA
Eli Paranoid El NA

E3 NA
El Other l3 NA
Circumstantial 121 NA
Situation t3 NA
[3 Immediate {Allergies Other



 

i

Other Medications:

 

i

 

 

 

Name: JEFFUS. DAVID Case#: 81873? Page: 3 of 4
Type: Crisis Screening Medicaidll: 519286114 Date: 10l07l2015
Printed cn oananme at 12:12 PM {Final Appmved on lonmm 5 at11:08 AM)

 

 

 

epakto 50 mg, lntuvi 2mg

 

Services Requested By Individual:

 

The client wens to go somewhere and gel evaluated. But he only wants to stay for 1 day.

 

 

IndividuallFamin Response:

 

The client's mom wants him to get some help in a hospital selling.

 

 

 

PreIiminary Treatment Plan or Action Plan
(INCLUDE RECOMMENDATIONS FOR ALTERNATE RESOURCES)

 

The client is suicidal and he has a plan to overdose. The client meets ontena to request admission.

 

TRR completed: 63 Yes 0 No

REFERRAL: MCOT El Hospital Referral Other
TYPE OF REFERRAL: 0 Voluntary Action 0 Court Commitment 0 Type Other

Disposition:

 

 

The client is suicidal and he has a plan to overdose. The client meets criteria to request admission.
Contested BHC in Tyler and had the information faxed over. Waiting for the Dr. to review the case
or admission.

 

 

 

HOSPITAL ADMISSION

STATE FACILITY ADMISSION RECOMMENDED: 0 Yes No?

I HAVE AUTHORIZED THE FOLLOWING PLACEMENT:

(9 ETBH PRH Longview Behavioral Hostpitai 0 Crisis Respite Other:
INSURANCE Yes 0 No

COMPANY NAME AND POLICY NUMBER: Health?rst: 551219999

MEDICAID G) Yes 0 No MEDICAID NUMBER 519286114

MEDICARE 0 Yes 0 No MEDICARE NUMBER

OTHER (SPECIFY):

 

 

 

Type: Crisis Screening Medicaid#: 519286114 Date: 10I07f2015
Printed on 0812312015 a: 12:12 PM  [Final Approved on zonmm 5 a! 11:08 

 

 

Name: Case#: 81873? Page: 40M 

 

 

 

ADMESSION DATE: NUMBER OF DAYS AUTHORIZED:

MCOT REFERRAL: (PLACE IN #8665 TO SEND TO MCOT HOMEPAGE)

 

Name: MATTHEWS, RICHARD - 864 Date: Time: 8:25 am. Electronic

Electronicaliy Signed

Signature of Clinician Completing Form:

 

Name: CAIN, KENNETH - 964 Professionai Desc:

Electronicaliy Signed

 

Date: 10r?08l2015 Time: 4:13 pm. Eiectronic
Signature of LPHA:

 

Name: KENNEDY, BREDGET - 969, LPC Professiona! Desc: LICENSED PROFESSIONL COUNSELOR

Electronicafly Signed

 

Date: 101'1212015 Time: 11:08am. Eiectronic