OH Mental Health and Addiction Services
Inpatient Psychiatric Precertification Form
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Referral InformationDate Sent to Permedion:
Hospital/Facility Name:
Contact Person:
Email address:
Phone: / Fax:
Address, City, St, Zip:
Provider NPI Number:
Date of Admission:
Admission source:
Involuntary admission: / Yes / No
Admission Type: / Pre-Admission / Emergency
Recipient Information
Recipient Last Name: / First Name: / Suffix:
Social Security #: / Medicaid ID#:
Gender: / Male / Female / Race: / DOB / Age:
Marital Status: / Single / Married / Divorced
Widowed / Other: (explain)
Living Arrangements: / Alone / Court Ordered / Group Home/Half-Way House
Homeless/ Shelter / Non-Relatives / Foster Home
Relatives / Nursing Home / Assisted/Supervised
Parents/Guardian / Spouse/Significant Other / Other: (explain)
Address:
City, St, Zip:
Telephone:
Responsible Party Information
Responsible Party (Last Name, First Name)
Telephone: / County:
Relationship: / Self / Parent(s)/Guardian / Court
Gov. Agency / Other: (explain)
Address same as recipient
Address:
City, St, Zip:
Initial Treatment
Axis I (Primary) / ICD-9/10
Additional Axis I: / ICD-9/10
Additional Axis I: / ICD-9/10
Additional Axis I: / ICD-9/10
Axis II: / ICD-9/10
Axis III (Primary): / ICD-9/10
Additional Axis III: / ICD-9/10
Additional Axis III: / ICD-9/10
Additional Axis III: / ICD-9/10
Axis IV: Psychosocial and Environmental Problems: (“X” and explain all that apply)
Problems with primary support group
Problems related to social environment
Educational problems
Occupational problems
Housing problems
Economic problems
Problems with access to Health Care Services
Problems related to interaction with legal system
Other psychosocial and environmental problems
Axis V: / Current GAF: / Past Year GAF:
Please “X” and explain all that apply:
Auditory hallucinations
Visual hallucinations
Delusions
Paranoia
Bizarre thinking
Thought content
Anxiety level
Appearance
Mood
Affect
Behavior
Speech
Cognition
Insight/Judgment
Sleep
Hygiene
Nutrition
Presenting Symptoms
Imminent risk to self through: (“X” all that apply and provide detail in box below)
Recent suicide attempt or serious self harm?
A current plan for self harm?
Command auditory hallucinations for Suicide or self harm?
Imminent risk to harm another through (“X” all that apply and provide detail in box below)
Recent Action
Current Plan
Command auditory hallucinations
Inability to care for self? (Provide details below)
Other psychosocial dysfunction or mental instability requiring psychiatric inpatient care?(Provide details below)
Severe disability requiring hospitalization due to the severe symptoms such as hallucinations, mania or acute psychosis? (Provide details below)
Discharge Plan: (Provide details below)
Current Medications
Please list all current medications:
Drug Name / Daily Dosage / Frequency / Start / Diagnosis
Compliant with Current Medications? / Yes / No / Not Applicable
Prior Psychotropic Medications
Please list all prior mediations
Drug Name / Daily Dosage / Start / End / Diagnosis
Compliant with Current Medications? / Yes / No / Not Applicable
Substance Abuse History
Please complete all applicable rows
Drug Name / Frequency / Last Use / Route / 1st Time / Amount per Use / Comments
Alcohol
Cannabis
Hallucinogens
Benzodiazepines
Inhalants
Amphetamines
Barbiturates
Narcotics
OTC Meds
Other
Impact of Substance abuse on treatment: (explain below)
Toxicology Screen Results:
Prior Treatment
Other Mental Health Interventions/Services (Please complete for each facility)
Agency/Facility Name / Type of Service / Dates of Service / Frequency of Service (Hours/day)
Legal History
Please “X” all apply and explain:
Current Legal charges
Pending court date(s)
Past legal issues
Current domestic violence in home
History of domestic violence
Physically destructive acts/property destruction
Currently on probation/parole
Abuse (Physical, Emotional, Sexual, Neglect, Elder, Other
Please “X” all apply and explain:
Recent Abuse
Past Abuse
Additional Information:
Health Home (if applicable)
County:
Agency:
Inpatient Treatment History
Prior Inpatient Treatment? / No / Yes(list dates, frequency, facility and outcome below)
Readmission within the past 30 days? / No / Yes
Number of lifetime admissions
Number of admissions in the past year
Please complete for each admission:
Month / Year / Facility / Length of Stay
Children & Adolescents Only (Under 21)
Please “X” all that apply and explain
The CON has been completed and signed by a physician and is on the medical record
Children’s Services involvement
Legal/Law enforcement involvement
Other Information
Geriatric Patients 65 years and older
Please “X” all that apply and explain (including onset):
Delirium (acute onset less than 48 hours)
Dementia
Disturbance in behavior (new)
Presence of psychosis (new)
If patient resides in a supervised setting, explain the need for inpatient level of care at this time:
Is this patient a transfer from another hospital to the current hospital? / Yes / No
Reason for transfer:
Is this patient a transfer from another unit to the current unit? / Yes / No
Other Pertinent Information
Please provide any other pertinent information that pertains to the inpatient admission:
I affirm all information is a true and accurate description of the above individual.
Completed by:
Date:
Revised 12/6/2013