Healthcare Mental Health Report

HEALTHCARE MENTAL HEALTH REPORT

Clinician:     License / Credentials:

Date of Report:     Date of Evaluation:     Location:

Patient Information

Male Female Non-binary

Insurance & Administrative

Referral & Presenting Problem

Psychiatric & Treatment History

Prior Psychiatric Hospitalizations: Yes No

Substance Use

Alcohol: Current Past None

Illicit Drugs: Current Past None

Medical History

Mental Status Examination

Risk Assessment

Suicidal ideation: Yes No

Homicidal ideation: Yes No

Low Moderate High

Diagnosis & Treatment Plan

Consent, Confidentiality & Authorization

I understand that mental health treatment records are confidential and will be maintained in accordance with applicable law. Confidentiality is limited in certain circumstances, including but not limited to: (1) suspected child, dependent adult, or elder abuse or neglect; (2) imminent risk of serious harm to self or others; (3) court order or other legal compulsion; and (4) required reporting of certain infectious diseases as mandated by law.

By signing below I consent to receive assessment and treatment from the clinician named above. I authorize the clinician and clinical staff to provide or coordinate treatment, to contact emergency or collateral supports if necessary, and to communicate with other health care providers for continuity of care when I have authorized such disclosures.

Authorization to share relevant clinical information with other providers (specified below) is voluntary and may be revoked in writing, except to the extent that action has already been taken in reliance on the authorization. This authorization expires on:

I acknowledge that I have received and reviewed the practice's privacy notice regarding health information practices and my rights. I understand the limits to confidentiality described above.

Acknowledgment: I acknowledge receipt of the privacy notice and consent to treatment as described.

Provider Summary / Clinical Impression (for official use)

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