Attachment for Petition for Emergency Protective Services Order

EXHIBIT A

PRE-REMOVAL MEDICAL ASSESSMENT REPORT

To be completed by a physician or osteopath only.

I am ______,

  • a licensed physician.
  • a licensed osteopath.

At the request of Adult Protective Services Division of the Texas Department of Family and Protective Services (APS), I performed a medical assessment as provided by §48.208(c)(4) of the Human Resources Code as a part of the determination of whether APS should seek an Emergency Order for Protective Services from the Court.

Date of Examination: ______. Place of Examination: ______.

Name of Client: ______. Age: ______. Sex: ______

Race or Ethnic group: ______.

I have previously treated this client. No _____. Yes.______

I observed the following concerning the client’s physical and medical condition:

______.

I observed the following concerning the client’s mental condition:

______.

Based on my observations, examination and professional assessment, I determined the following:

PART I

Threat to Life or Physical Safety

( ) YES, the client is suffering from abuse, neglect or exploitation to a degree that it presents a threat to life or physical safety, because: (explain medical threat) ______.

( ) NO, the client is not suffering from abuse, neglect or exploitation to a degree that it presents a threat to life or physical safety.

PART II

Capacity to Accept or Reject Services

( ) Lacks Capacity: At this time, the client lacks capacity to consent to or reject protective services because the client’s mental or physical impairment is such that the client is incapable of understanding the nature of the services offered and the consequences of rejecting protective services.

( ) Has Capacity: The client has capacity to understand the consequences of consenting to or rejecting services.

CONCLUSION

(If the answer to PART I is “Yes” and PART II is “Lacks Capacity”)

( ) YES, for the reasons given above, it is my professional opinion that issuance of an Emergency Order Authorizing Protective Services without the client’s consent is necessary.

(If the answer to PART I is “No” or PART II is “Has Capacity”)

( ) NO, it is my professional opinion that the issuance of an emergency order authorizing protective services without the client’s consent is not justified.

Signed this ______day of ______, 200__.

Signature
______
Printed Name ______
Title:______

EXHIBIT A

NURSES ASSESSMENT

I am ______, a registered nurse. I have training and experience in performing this type of assessment as required by §48.208(c-1) of the Human Resources Code.

At the request of Adult Protective Services Division of the Texas Department of Family and Protective Services (APS), I performed a nursing assessment as provided in §48.208(c-4) of the Human Resources Code as a part of the determination of whether APS should seek an Emergency Order for Protective Services from the Court.

Date of Examination: ______. Place of Examination: ______.

Name of Client: ______. Age: ______. Sex: ______

Race or Ethnic group: ______.

I observed the following concerning the client’s health status:

______.

Based on my observations, examination and professional nursing judgment, I determined the following:

1. The client is likely to be suffering from abuse, exploitation, or neglect:

No ______Yes. (explain) ______.

2. This abuse, neglect or exploitation may present a threat to life or physical safety:

No. ______. Yes: (explain threat) ______

______.

3. I have reported my assessment to a physician, Dr. ______.

Signed this ______day of ______, _____

Signature

______

Printed Name ______

Title: Registered Nurse

PHYSICIAN’S OPINION BASED ON REGISTERED NURSE’S ASSESSMENT

______, a registered nurse has reported to me her assessment of ______, an APS client. As provided by §48.208(c-5) of the Human Resources Code, based on this nursing assessment of the client’s health status, it is my opinion that:

1. The client is reported to be suffering from abuse, exploitation, or neglect:

No ______Yes. (explain) ______.

2. This abuse, neglect or exploitation may present a threat to life or physical safety:

No. ______. Yes: (explain threat) ______

______.

3. It is my professional opinion that the issuance of an emergency order authorizing protective services without the client’s consent is advisable because of the following circumstances: ______.

Signed this ______day of ______, _____

Signature

______

Printed Name ______

Title:______

EXHIBIT A

PSYCHOLOGICAL STATUS REPORT

I am ______, a licensed psychologist/master social worker. (circle one) I have training and experience in issues related to abuse, neglect and exploitation as required by §48.208(c-3) of the Human Resources Code.

At the request of Adult Protective Services Division of the Texas Department of Family and Protective Services (APS) I performed a psychological assessment as provided in §48.208(c-3) of the Human Resources Code as a part of the determination of whether APS should seek an Emergency Order for Protective Services from the Court.

Date of Examination: ______. Place of Examination: ______.

Name of Client: ______. Age: ______. Sex: ______

Race or Ethnic group: ______.

I observed the following concerning the client’s psychological status:

______.

Based on my observations, examination and professional assessment, I determined the following:

1. The client is reported to be suffering from abuse, exploitation, or neglect which may present a threat to life or physical safety: No ______Yes._____ (explain)______

______.

2. It is my professional opinion that the issuance of an emergency order authorizing protective services without the client’s consent is necessary because of the following circumstances: ______.

Signed this ______day of ______, _____

Signature
Printed Name ______
Title:______

EXHIBIT A

HEALTH STATUS REPORT

To be completed by a physician’s assistant or advanced practice nurse only.

I am ______, a licensed physician’s assistant/ advanced practice nurse. I have training and experience in performing this type of assessment as required by §48.208(c-1) of the Human Resources Code.

At the request of Adult Protective Services Division of the Texas Department of Family and Protective Services (APS) I performed a health assessment as set forth in §48.208(c-2) of the Human Resources Code as a part of the determination of whether APS should seek an Emergency Order for Protective Services from the Court.

Date of Examination: ______. Place of Examination: ______.

Name of Client: ______. Age: ______. Sex: ______

Race or Ethnic group: ______.

I observed the following concerning the client’s health status:

______.

Based on my observations, examination and professional assessment, I determined the following:

1. The client is reported to be suffering from abuse, exploitation, or neglect presenting a threat to life or physical safety: No _____ Yes. (explain) ______.

2. The Client provided medical history to me. No._____. Yes. (explain) ______.

3. It is my professional opinion that the issuance of an emergency order authorizing protective services without the client’s consent is advisable because of the following circumstances: ______.

Signed this ______day of ______, 200__.

Signature
Printed Name ______
Title:______

Form 50101

Physician/Osteopath