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Depression Monitoring Flow Sheet

Patient Name:

DOB:

Symptoms

 DATE

 DATE

 DATE

 DATE

 DATE

 

 Week

 Week

 Week

 Week

 Week

 Mood

 

 

 

 

 

 Interest

 

 

 

 

 

Appetite/weight

 

 

 

 

 

 

Sleep

 

 

 

 

 

 

 

Psychomotor

 

 

 

 

 

 

 

Fatigue

 

 

 

 

 

 

 

Self-Esteem

 

 

 

 

 

 

 

Concentration

 

 

 

 

 

 

 

Death/Suicide

 

 

 

 

 

 

 

PHQ-9 Score

 

 

 

 

 

 

 

Function -PHQ-9 #2 Question

 

 

 

 

 

 

Patient Impression

 

 

 

 

 

 

 

 

Contact With Patient/ Phone = P Visit = V

 

 

 

 

 

 

MH Referral

 

 

 

 

 

 

 

Medications/

Dosage

 

 

 

 

 

 

 

 

 

 

Patient Compliant With Recommendations

 

 

 

 

 

 

 

 

 

 


 Processing Referrals for Psychiatric Services

Sequence in Referral Process

1. Primary care physician recognizes need for mental health referral.
 
2. Primary Care Physician explains reasons for mental health referral and
recommends appropriate level of care and type of psychotherapy services
(i.e. counselor, psychologist, psychiatrist).
 
3. Patient may not agree to seek help from a mental health professional. If patient
resists, physician and/or office staff provides education, support and counseling,
and reinforce need for mental health referral.
 
4. Referral form is completed and mental health professional is selected by the patient, depending upon many factors, such as geographic location, insurance coverage, goals of treatment, and if combined therapy with antidepressants are being used.
 
5. Communication from the Primary Care Physician (PCP) is sent to the mental health professional on the "Referral to Mental Health Form" when the referral is made. The PCP includes his/her office information, such as address, phone and fax numbers on the form, to facilitate communication.
 
6. Mental health professional begins treating the patient and communicates response and recommendations back to the primary care physician, using the "Model Communication Form Mental Health".
 
7. Primary care physician and mental health professional continue to communicate and coordinate patient treatment, until problems are resolved.
 
Referral to Mental Health Services

Patient Name:

Date:

1. Goal(s) of Treatment as Identified by Patient:

A.

B.

C.

D.

2. Primary Care Physician Recommendations for Psychotherapy Treatment

 

Type of Therapist: q Counselor q Psychologist q Psychiatrist

 

Reason for Referral:

 

 

3. Medical History Related to Psychiatric Diagnosis

 

 

4. Previous Treatment for Psychiatric Problems

 

 

5. Current Medications

 

Drug Dose Frequency

 

 

 

 

Note to MH Professional: Primary Care Physician Information:

Please communicate with

Name:

Address:

Phone:

Fax:

 

Model Communication Form Mental Health - PCP

Patient Name:

Date:

 

Therapist Providing Patients Care: Week ________ of Treatment

Name & Title:

Address:

Phone:

Fax:

 

1. Diagnostic Impression:

 

 

 

2. Treatment Information:

 

 

 

Treatment Patient Response to Treatment

Type/dosage of Antidepressants Type of Therapy(s) Initiated

q Cognitive Behavioral Therapy
q Interpersonal Psychotherap
q Marital Therapy
q Brief Dynamic Psychotherapy
q Other

 

 

3. Patient Response to Treatment and Recommendations for PCP Treatment