Any County Jail
Any Criminal Justice Center
234 Any Street.
Some Town, YY 12347 / Mental Health Initial Assessment / CSS
Correctional Service
System
Patient Name
Collette Rose / Inmate Number
234568 / Booking Number
987655 / Birth Date
12/04/1978 / Date of Service
04/07/2012

Reviewed Receiving Screen? þYes ☐ No

Chief Complaint and History of Present illness- Subjective

I/m was seen by mh due to a referral from medical reporting hx of tx for Bipolar Disorder and Major Depression at County General Hospital. Presently I/m reports that she is feeling sad and has no energy to keep up with her hygiene or report for counts. She describes a general pain that she feels but can’t indicate a physical cause. COs report her crying and staring blankly at the walls.

Psychiatric History

ROI Verified: þ Yes ☐ No

Outpatient Treatment: ☐ Current ☐ History þ None

Where: N/A

Inpatient Treatment: ☐ Current þ History ☐ None

Where: County General Hospital

Medication: ☐ Current þ History ☐ None

List: Seroquel, Lamictal, Prozac, Lithium

Family History:

Violence History: ☐ Yes þ No

Abuse History: þ Physical þ Sexual ☐ None

Substance Abuse: þ Current þ History ☐ None

þ ETOH ☐ THC ☐ Cocaine þ Other: unspecified

Marital Status: Single Family/Significant Other supportive? þ Yes ☐ No

Employed? ☐ Yes þ No Education (highest grade achieved):8th grade

Level of Cognitive Functioning: Average

Suicide Potential Screening

Expresses thoughts of killing self ☐ Yes þ No

Helplessness & Hopelessness (lack of future oriented thoughts) þ Yes ☐ No

Suicide Plan or Instrument in possession ☐ Yes þ No

Previous suicide attempt þ Yes ☐ No

Family/Significant Other attempted or died by suicide ☐ Yes þ No

Major problems other than legal þ Yes ☐ No

Psychiatric History þ Yes ☐ No

Currently under influence of Alcohol/Drugs ☐ Yes þ No

Overly anxious, afraid, withdrawn þ Yes ☐ No

Position of Respect in community- alleged crime is shocking in nature-

expresses feelings of shame or embarrassment ☐ Yes þ No

If there are any “Yes” answers to Red questions, or total # of “Yes” answers is 5 or more, a full mental health assessment should be performed.

Medical History

☐ DM þ HTN ☐ HIV ☐ HEP ☐ Other

History of Neurological disorders? ☐ Yes þ No

þ Current Medications in jail

See ERMA

Legal History

Current Charge: Larceny

Date of Arrest: 04/01/2012 # of Arrests/Incarcerations: 6 Bound Over? ☐ Yes þ No

þ Court/Release date scheduled: 06/01/2012

Assessment

Appearance:

☐ Appropriate ☐ Meticulous þ Unclean ☐ Disheveled ☐ Bizarre ☐ Other

Speech:

☐ Appropriate ☐ Expressive ☐ Loud þ Slowed ☐ Pressured ☐ Slurred ☐ Other

Mood:

☐ Appropriate þ Depressed ☐ Euphoric ☐ Anxious ☐ Angry ☐ Irritable ☐ Other

Affect:

☐ Appropriate þ Tearful ☐ Blunted ☐ Flat ☐ Labile ☐ Hostile ☐ Other

Thought Form:

☐ Coherent ☐ Circumstantial ☐ Tangential ☐ Loose Associations þ Poverty of Thought ☐ Flight of Ideas ☐ Other

Thought Content:

þ Appropriate ☐ Compulsive/Obsessive ☐ Thought Insertion ☐ Broadcasting ☐ Delusional ☐ Other

Orientation:

þ Person þ Place þ Purpose þ Time

Intelligence:

☐ Above Average þ Average ☐ Below Average ☐ Developmentally Disabled

Memory:

þ Intact ☐ Immediate ☐ Recent ☐ Remote

Insight:

☐ Intact ☐ Good þ Fair ☐ Poor

Judgment:

☐ Intact ☐ Good þ Fair ☐ Poor

Behavior:

☐ Appropriate ☐ Belligerent ☐ Agitated þ Withdrawn

Assessment Summary:

I/m presented with depression, low energy, crying spells and sleep disturbances. Her mood was depressed, affect was tearful, she didn’t respond to many of this writer’s questions. Her thought content was appropriate and she was oriented x4. I/m has intact memory, fair insight, fair judgment and withdrawn behavior. I/m denies ah/vh. I/m reports having been to County General Hospital and has taken psychiatric medications. I/m is not currently taking medications but does want something to “take the pain away”. I/m has been referred to the mh provider. MHS to f/u as needed. Joshua Hamilton, LCSW

Impression

Axis I: R/O Bipolar Disorder I

Axis II: Defer

Axis III: Defer

Axis IV: Legal, Employment, Housing

Axis V: 40

Plan

☐ Mental Health Treatment not indicated at this time- MH will follow up as needed.

☐ Mental Health Specialist follow-up.

☐ Initiate/discontinue suicide precaution protocol.

☐ Referral to medical staff

þ Referral to provider

☐ Requested collateral information, chart review.

☐ Allow 4 weeks for sobriety.

☐ Other:

E-Signed by Joshua Hamilton on 04/10/2012 01:50 PM ET

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