IWS Tulare Adult 4011.6 Report
Patient Name:
Patient Date of Birth
-
Month
-
Day
Year
Date
Case Number:
Information from Court Referral:
Behaviors reported by custody staff, mental health staff, medical staff (past 1 week):
Programming well
Not programming
Socializing with peers/staff
Isolating
Taking care of hygiene
Poor hygiene
No self harm behaviors
Has engaged in self harm behaviors
No violent behaviors
Has been violent with peers or staff
Taking Medications
Refusing medications
Participating in treatment
Refusing treatment
Other
Email of Psychiatrist/Director who will complete the rest of this form:
ray4531@netzero.com
rama.yasaei@kaweahhealth.org
mbryan@kaweahhealth.org
asaada@kaweahhealth.org
mbagga@goodsamhospital.com
kfreeman@inwellsoln.com
Submit to Psychiatrist/MH Director
Submit to Psychiatrist/MH Director
Psychiatrist that saw the patient:
Please Select
Dr. Kurra
Dr. Kehal
Dr. Yasaei
Dr. Bryan
Dr. Saadabadi
Dr. Bagga
Dr. Sangani
Jackie Espino, PHMNP
Eehai McCarty, PHMNP
N/A
Date of Evaluation:
-
Month
-
Day
Year
Date
Symptoms noted during their evaluation:
Patient denied all symptoms and is RELIABLE
Patient denied all symptoms but is UNRELIABLE
Feelings of depression
Hearing Voices
Seeing things
Feeling suicidal
Thoughts of wanting to hurt others
Other
Reasons why patient is unreliable:
Behaviors noted in my evaluation:
Calm and Cooperative
Agitated
Restless
Verbally aggressive
Crying/Tearful
Current Medications:
Current Diagnoses:
Treatment:
Patient has been taking medications as prescribed
Patient has been refusing medications
Patient has not been started on medications due to lack of symptoms
Patient has not been started on medication due to lack of participation in evaluation
Patient has not been started on medications due to lack of parental or guardian consent
Other
Has the patient reported any side effects to the medications?
Yes
No
N/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 is
Continue to increase/change medications to address symptoms
Continue visits with Clinician
Patient will be seen only as needed
Other
I have access to and have been able to review outside records:
Yes
No, assistance in obtaining records would be appreciated from the court.
No, records are not needed at this time
Physician/Mental Health Director Signature
Completed By:
Date
-
Month
-
Day
Year
Date
Submit to Courts
Submit to Courts
Background use only
Email for forwarding
example@example.com
Should be Empty: