Fill and Sign the Dominion Power Medical Form

Submit this document to: VCCB Department of Administration PO Box 110230 Juneau, Alaska 99811-0230 Facsimile – 907-465-3040 STATE OF ALASKA VCCB INITIAL RESPONSE AND ASSESSMENT: FORM II Please submit this form if more than six sessions are indicated for successful treatment. If six sessions or less are indicated, please complete Form I. Payment for treatment provided is dependent upon the processing and approval of the VCCB application for compensation. Victim’s Name VCCB Claim Number _______________________________________ ________________________ Client’s Name (if different then the victim’s) Date treatment began _______________________________________ ________________________ Clinician’s Name and Provider Number Number of sessions to date ________________________ ______________ ________________________ Clinician’s Address Clinician’s Phone Number _______________________________________ ________________________ ________________________________________________________________________ Please review the VCCB guideline on Initial Response, Assessment and Documentation Procedures and provide answers to the questions listed below. You may copy and complete this form, or send a narrative report that contains all of the points listed below. 1) What is the victim’s or caregiver’s initial description of the crime incident for which they have filed a VCCB claim? If the victimization was not recent, please describe what brought the victim into treatment at this time. If the crime occurred more than two years prior to the date of the VCCB application, justification for the Board’s consideration of waiving the twoyear time limit imposed by statute must be included. ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 2) Briefly summarize the essential features of the victim’s symptoms, related to the crime impact, beliefs/attributions, vulnerabilities, defenses and/or resources that led to your clinical impression. (Refer to the DSM IV and VCCB Guideline on Initial Response, Assessment and Documentation Procedures.): 3) Please describe pre-existing or co-existing emotional/behavioral or health conditions relevant to the crime impact if present, and explain how they were exacerbated by the crime victimization (e.g., depression, anxiety, vulnerabilities in personality structure, etc.). 4) List diagnoses on all 5 Axes (be certain all diagnostic criteria are met). Axis I: ________________________________________________________________________ Axis II: Axis III: Axis IV: Axis V/Current GAF: Highest GAF past year: 5) Treatment plan (based on diagnosis and related symptoms, see the VCCB guideline on Initial Response, Assessment, and Documentation Procedures) A. What are the specific treatment goals that you and the victim have set? Please also list who, in addition to the victim, you expect to include in treatment sessions e.g., parent(s), significant other. B. What are the treatment strategies to achieve these goals? C. How will you measure progress toward these goals? D. Describe auxiliary care that will be incorporated (e.g., psychiatric evaluation, medication management, spiritual healers, community services or other services). 6) Please describe your assessment of the victim’s treatment prognosis, as well as any extenuating circumstances and/or barriers that might affect treatment progress (e.g., previous trauma history, pre-existing emotional/behavioral or medical conditions, family and social support system response and dynamics, religious/spiritual belief, cultural practices, involvement in criminal justice system or proceedings involvement with Child Protective Services, etc.). 7) Has the victim experienced time loss from work as a direct result of the victimization? ____ No ____ Yes; Please list the date(s) the person was not able to work and if applicable give an estimated date when the individual should be able to return to work. Please explain why the time loss has occurred, the extent of the impairment and the prognosis for future occupational functioning. Dates:__________________________________________________________________ 8) Does the victim live beyond the immediate vicinity? If so, approximately how many miles must be traveled? Does the victim need air transport to receive counseling? ____ No ____ Yes; Please indicate approximate number of miles driven to receive counseling or if airfare is involved, please indicate. _____________________________________________________________________