IWS Tulare JDF Judge's Report

IWS Tulare JDF Judge's Report
Patient Name:
Patient Date of Birth

MonthDayYear
Date
Case number:
Information from Court Referral:
Behaviors reported by custody staff, mental health staff, medical staff (past 1 week):

Programming wellNot programmingAttending school/classesProblems with school attendance or participationSocializing with peers/staffIsolatingTaking care of hygienePoor hygieneNo self harm behaviorsHas engaged in self harm behaviorsNo violent behaviorsHas been violent with peers or staffTaking MedicationsRefusing medicationsParticipating in treatmentRefusing treatmentOther
Email of Psychiatrist/Director who will complete the rest of this form:

ray4531@netzero.comrama.yasaei@kaweahhealth.orgmbryan@kaweahhealth.orgasaada@kaweahhealth.orgmbagga@goodsamhospital.comkfreeman@inwellsoln.comgkehal@goodsamhospital.com
Psychiatrist that saw the patient:
Date of Evaluation:

MonthDayYear
Date
Symptoms noted during their evaluation:

Patient denied all symptoms and is RELIABLEPatient denied all symptoms but is UNRELIABLEFeelings of depressionHearing VoicesSeeing thingsFeeling suicidalThoughts of wanting to hurt othersOther
Reasons why patient is unreliable:
Behaviors noted in my evaluation:

Calm and CooperativeAgitatedRestlessVerbally aggressiveCrying/Tearful
Current Medications:
Current Diagnoses:
Treatment:

Patient has been taking medications as prescribedPatient has been refusing medicationsPatient has not been started on medications due to lack of symptomsPatient has not been started on medication due to lack of participation in evaluationPatient has not been started on medications due to lack of parental or guardian consentOther
Has the patient reported any side effects to the medications?

YesNoN/A patient not currently prescribed medications or not taking them
What are the reported side effects and how are they being addressed?
Summary for Court:
Plan:

Continue current medications as isContinue to increase/change medications to address symptomsContinue visits with ClinicianPatient will be seen only as neededOther
I have access to and have been able to review outside records:

YesNo, assistance in obtaining records would be appreciated from the court.No, records are not needed at this time
Physician/Mental Health Director Signature

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