Outpatient Review Form-Adult Day Treatment

Please Fax to Beacon Health Options:
Outpatient Review Form
(Adult Day Treatment)
800.441.2281 / 781.994.7634
Member information (Verify eligibility before rendering services)
Member ID#:
Member name:
D.O.B:
Provider information
Provider / agency name:
Clinician name:
Provider ID#:
Phone number:
Request for Adult Day Treatment - H2012
sessions, starting on:
I request
over the next:
90 days
Other:
180 days
Current psychotropic medications
Are psychotropic meds being prescribed?
Yes*
Unknown
No
*If Yes, prescribed by:
MD
RN
CS/NP
PCP
List Meds:
Prescriber:
Have you communicated with the member’s prescriber of psychotropic drugs?
Yes
No
Member declined
N/A; Member not on medications
Have you communicated with member’s PCP?
Yes
No
N/A; Provider is the prescriber
Member declined
Have you documented the communication or member declination?
Yes
No
N/A; I did not contact PCP
Have you been in communication with other BH providers for this member?
Yes (please specify):
No
Member declined
N/A; There are no other BH providers
Site of treatment
Office
School
Home
Other (please specify):
Additional Comments:
ICD-10/DSM-5 diagnoses (Please give more than one diagnosis as necessary for clinical presentation.)
Diagnosis:
Diagnosis:
Diagnosis:
Diagnosis:
Current risk indicators (check all that apply):
Current substance abuse
Caring for ill family member
Current family violence
Fire setting
Impulsive behavior
Coping with significant loss
Prior Psychiatric Inpt. Admission
Self-mutilating / cutting
Assaultive behavior
Other (please specify):
Sexually offending behavior
Psychotic symptoms
Status of 3 most significant objectives since treatment initiation (Please include additional page if space provided is insufficient.)
Modality
Objectives
Progress
(Individual/Group)
(in measureable/behavioral detail)
(Rating since Tx began; use scale below)
1.
2.
3.
N = New Goal
1 = Much Worse
2 = Somewhat Worse
3 = No Change
4 = Slight Improvement
5 = Much Improvement
Risk assessment (Check all that apply)
Suicidality:
Homicidality:
Not present
Ideation
Not present
Plan
Ideation
Rate member’s level of psychological distress:
Current risk of psychiatric hospitalization*:
Means
Plan
Means
1 (minimal)
1 (minimal)
Prior Attempt (please specify date):
Prior Attempt (please specify date):
2 (mild)
3* (moderate)
2 (mild)
*If 3 or higher, have you created/reviewed a crisis plan for this member?
*If yes does member have a copy?
Yes
4* (marked)
3* (moderate)
Yes*
4* (marked)
No
5* (severe)
5* (severe)
Member declined
No
Has the member been in higher level of care in the last 12 months?
Was a standard instrument used to evaluate treatment progress?
Yes
Yes*
No
No *If yes, name instrument(s):
Beacon Health Strategies, LLC is a Beacon Health Options company.
R = Resolved