Community Care of the SandhillsTelepsychiatry ToolkitMay 2016

Table of Contents

I. TELEPSYCHIATRY CONTACTS and REFERRAL PROCESS

Contacts

Referrals

A Typical Telepsychiatry Encounter

Equipment

II.easter seals telepsychiatry consult information form

III.Easter Seals Face Sheet

IV.Easter seals general consent for treatment

V.El Futuro Telepsychiatry Referral Form......

VI.el futuro screening form

VII.el futuro consent for treatment

IX.el futuro Authorization to release and obtain confidential information

XI.grant related documents

Telepsychiatry patient satisfaction survey

Telepsychiatry Practice Satisfaction Survey

I. TELEPSYCHIATRY CONTACTS and REFERRAL PROCESS

Contacts

Community Care of the SandhillsAndy Smitley, Project Coordinator

Easter Seals UCPKristen Cuthbertson, Administrative Assistant

Easter Seals Contact for Pediatric Patients (Dr. Saranga)

(919) 865-8710 Main

(919) 256-0772 Fax

El Futuro, Inc.Sarelli Rossi, MHA,Associate Director

(919) 688-7101 Ext. 603

(919) 688-7102 Fax

Referrals

Easter Seals

  • Pediatric and adult appointments through Easter Seals are assigned on a first-come, first-serve basis (please visit your schedulicity.com account to view Dr. Saranga’s schedule and availability). Please book all appointments through schedulicity.com and confirm by faxing referral documents to Easter Seals. Please plan to have all referral documents submitted at least 48 hours in advance. Referrals to Easter Seals must include an Easter Seals Telepsychiatry Demographic/Face Sheet, Consent for Telepsychiatry and Intake Form.

El Futuro, Inc.

  • Appointments for Spanish speaking patients can be scheduled with El Futuro, Inc. Clinics must fax the referral packet to (919) 688-7102, Attn: Sarelli Rossi. Appointments can either be scheduled through schedulicity.com or by email (). A completed referral packet must be received by El Futuro prior to scheduling appointment.

A Typical Telepsychiatry Encounter

This project follows a consultative model, meaning the psychiatrist will perform a thorough assessment and write a comprehensive treatment plan for the primary care provider to follow:

Equipment

Carousel Industries’ staff takes pride in offering our customers responsive, competent and excellent service. We recognize our customers are the most important part of our business and we strive to ensure your complete satisfaction.

Below, are instructions on reporting issues and requesting service.

Service and Support Requests:

Issues and questions may be reported by calling the Carousel Service Center

Toll Free:
866-408-4596

Requests may also be opened via email to:

II.easter seals telepsychiatry consult information form

Reason for your visit today:

Have you seen a psychiatrist or therapist before?Yes No

List any medical problems (including cardiac problems in client or close family members):

Current medications and dosage: Any side effects?:

Previous medication trials:

Allergies:

Hospitalization (Medical and Psychiatric):

Legal problems (current and past):Yes No

Substance abuse?Yes No Suicide attempts? Yes No

Violent behavior?Yes No

Family history of: mental illness? Yes No

For Minors

Currently living with:

Employment status of parents/guardian:

History of abuse or trauma:

Foster placements (Include ages):

Child Protective Services involvement:

Early Developmental issues:

Academic issues:

Current grade: In Special Ed?

III.Easter Seals Face Sheet

Telepsychiatry Face SheetTel: (919) 865-8710fax: (919) 256-0772

Date:

First Name: MI: Last Name:

DOB: Sex: Race: SS#:Marital Status:

Primary Insurance:Policy #:

Secondary Insurance:Policy #:

Home Address:

City: State: Zip:County:

Home Phone:Cell Phone:

Email:

IV.Easter seals general consent for treatment

GENERAL CONSENT FOR TELEPSYCHIATRY TREATMENT

I hereby authorize telepsychiatry treatment by a physician of Easter Seals UCP. I understand that “telepsychiatry” means I will be seeing the doctor on a television in this clinic and the doctor will see me on their television in their office. I understand I will be able to talk back and forth, just the same as if the doctor were actually sitting in the room with me. This system has been put into place to help me access care in a timely way and reduce a likely longer wait to receive services.

I understand that I do not have to participate in telepsychiatry treatment, but I will have to wait and schedule a visit with another provider, perhaps in a distant community, which could be days or weeks.

I understand there is a chance that while talking with the doctor over the television, there could be an interruption due to equipment failure. This can usually be fixed quickly and is akin to the doctor being called out of the room briefly as if they were actually here seeing me in person.

I understand the doctor will take notes for the medical record and will make treatment recommendations the same as if I saw them in person. Of course, this is confidential medical information.

I understand my privacy will be protected and no other television except the one in the room with my doctor will have my picture on it. No video recording of the visit with my doctor will be made and no other individuals, either here or in my doctor’s office will see or hear anything I have said to the doctor without my permission.

Patient Name: Date:

Patient/Guardian Signature:

V.El Futuro Telepsychiatry Referral Form

TELEPSYCHIATRY REFERRAL TO EL FUTURO

VI.el futuro screening form

el futuro screening form

Personal Information

Client’s Name:IMS #

SS#: ______-______-______(Required for Clients with Insurance)

Date of Birth:

Mailing Address:

Physical Address:

Telephone No. :home:cell:

County of Residence:

Sex:

Referral Source?

Emergency Contact (must be different from telephone number mentioned above)

Name:Telephone number:

Relationship to Client:(mother, father, uncle, aunt, spouse, sibling, friend)

I authorize El Futuro to contact this person if they need to contact or find me.

______(Please initial if you agree with statement)

For Child clients

Father’s Name:Phone #: (if different from above):

Country of Origin:

Mother’s Name:Phone #: (if different from above):

Country of Origin:

Notes about custody:

For women only:Are you pregnant?Yes____No____

Marital Status:Married:______Single:______(never been married)Divorced:______

Separated:______Widow:______Domestic Partner:______

Race/Country of Origin:

Time in USA: yearsmonths (optional)

Client’s allergies:

Employment information:

Part-Time:______Full time:______Unemployed:______Retired:______Season/Migrant Worker:______

Not in work force: Homemaker:______Student:______

County of employment:

Type of employment:

Primary doctor or clinic name:

Name and ages of children (if any):

Education:

Highest grade completed:

Primary language:

Bilingual?Yes:_____ No:______

Student?Yes:_____ No:______Part-time:______Full-time:______

If the client is a student:

School Name:

Current grade:

County school in:

Client:______IMS No.______

VII.el futuro consent for treatment

consent for treatment

Name of the Person Giving Consent:

(Name of mother or father if client is a minor).

Relationship to the Client:

( )Client (adult or emancipated minor)

( )Mother or father

( )Legal guardian

( )Other (specify):

I give my consent to “El Futuro” to provide the services indicated below:

( )Evaluation

( )Outpatient services

( )Other (specify):

In a medical emergency, I authorize the program to administer first aid.

If my doctor is not available, I authorize “El Futuro” to call a doctor or dentist, or to transport the client to the closest hospital, by ambulance if necessary. I will be responsible for paying all related costs.

I understand that I can discontinue this consent whenever I wish. This consent is effective until the completion of services. I understand this authorization completely and I give my consent freely.

______I give El Futuro permission to call and leave voicemail messages at the phone numbers I provided.

Signature

( ) Client ( ) Father ( ) Mother ( ) Guardian

Witness

Date

Name:IMS#Date:

consentimiento para el tratamiento

Nombre de la persona que esta dando consentimiento:

(Nombre de madre o padre si el cliente es menor de edad).

Relación al cliente:

( )Cliente (adulto o menor emancipado)

( )Madre o padre

( )Tutor(a) legal o guardian

Doy mi consentimiento a “El Futuro” para proporcionar los servicios indicados debajo:

( )Evaluación

( )Servicios en oficina, clinica o comunidad

( )Otro (especifique):

En una emergencia médica, autorizo al programa a la administración de primeros auxilios.

Si mi médico no esta disponible, autorizo a “El Futuro” para llamar a un médico o dentist, o a transporter al cliente nombrado hasta el hospital más cercano, por ambulancia si es necesario. Entiendo que seré responsible por todos los gastos incurridos.

Entiendo que puedo descontinuar este consentimiento en cualquier momento. Este consentimiento es efectivo hasta la fecha de finalización de los servicios. Entiendo esta autorización completamente y doy mi consentimiento libremente.

______Le doy permiso al El Futuro a dejar mensajes de voz en los numerous de teléfono que he brindado.

Firma

( ) Cliente ( ) Padre ( ) Madre ( ) Tutor(a)

Testigo

Fecha

Name:IMS#Date:

VIII.el futuro Authorization to release and obtain confidential information

XI.grant related documents

Telepsychiatry Patient Satisfaction Survey

This form is to be completed by the patient following the appointment. Please fax to Community Care of the Sandhills (910) 295-7251.

Telepsychiatry Practice Satisfaction Survey

This form is to be completed by the practice point person following each appointment. Please fax to Community Care of the Sandhills (910) 295-7251.

Community Care of the SandhillsTelepsychiatry ToolkitMay 2016