Depression Monitoring Flow Chart

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
         


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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.

Previous section
Referral to Mental Health Services

Patient name: ___________________________________   Date: ___________________

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

A.________________________________________________________________________

B.________________________________________________________________________

B.________________________________________________________________________

D.________________________________________________________________________

2. Primary Care Physician Related to Psychiatric Diagnosis

  Type of Therapist:        Counselor         Psychologist         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:
Please communicate with
->
Primary Care Physician Information:
Name:
Address:
Phone:
Fax:
Previous section
Model Communication Form Mental Health - PCP


Patient name: ___________________________________   Date: ___________________
Therapist Providing Patient's Care: Week___________of Treatment

Name & Title:
Address:
Phone:
Fax:

1. Diagnostic Impression:
________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

2. Treatment Information:

 Treatment                                                Patient Response Treatment                


Type/dosage of Antidepressants

__________________________________

__________________________________

__________________________________

Type of Therapy(s) Initiated

Cognitive Behavioral Therapy
Interpersonal Psychotherapy
Marital Therapy
Brief Dynamic Psychotherapy
Other___________________


3. Patient Response to Treatment and Recommendations for PCP Treatment

__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________

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