The intersection of family involvement and involuntary mental health treatment underlines the significance of the AB 1424 form, a legislative artifact shaped by California Assembly Bill 1424 (2001). This bill mandates that decision-makers in involuntary treatment scenarios must consider the insights provided by family members and other concerned parties. Crafted through collaborative efforts involving Alameda County Behavioral Health Care Services, the Alameda County Family Coalition, mental health consumers, providers, patients' rights advocates, and the judicial system, the AB 1424 form embodies a structured approach to amalgamating historical mental health information provided by those closely connected to the patient. This ensures a more holistic view of the patient's needs and history is taken into account during the decision-making process for involuntary treatment. Furthermore, the form enshrines certain rights for both the consumer—such as the right to access their mental health chart—and the submitting family member, including the ability to withdraw consent for the information shared, thus emphasizing the balance between necessary information sharing and the protection of individual rights. The detailed nature of the form, capturing everything from basic identification details to comprehensive mental health history, substance abuse issues, and current medication regimens, reinforces the complexity of considerations surrounding mental health treatment and the critical role that informed consent and family input play in optimizing care outcomes.
| Question | Answer |
|---|---|
| Form Name | Ab 1424 Form |
| Form Length | 3 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 45 sec |
| Other names | ca, Insurer, eb1424 form alameda, 2001 |
If available, this document should accompany the 5150 to the receiving facility.
Alameda County Behavioral Health Care Services
Historical Information Provided by Family Member or Other Interested Party
California Assembly Bill 1424 (2001), now a law, requires all individuals making decisions about involuntary treatment to consider information supplied by family members and other interested parties. Mental health staff will place this form in the consumer’s mental health chart. Under California and Federal law, consumers have theright to view their chart The Family member completing this form has the right to withdraw consent to release information given by them and have the information regarded as confidential {Welfare & Institutions Code 5328(b)}. This form was developed jointly by Alameda County Behavioral Health Care Services, Alameda County Family Coalition, family members, mental health consumers, mental health providers, patients’ rights advocates and the judicial system in order to provide a means for family members and other interested parties to communicate the client’s mental health history pursuant to AB 1424.
Name of Consumer __________________________ Date of Birth ____________ Phone _________
Address __________________________________________________________________________
Primary Language______________________________ Religion____________________________
Name of Private Medical Insurer ______________________________________________________
Yes No
Yes No
Yes No
Please ask the consumer to sign an authorization permitting Alameda County mental health providers to communicate with me about his/her care.
I wish to be contacted as soon as possible in case of emergency, transfer or discharge.
The consumer has a Wellness Recovery Action Plan (WRAP) or Advance Directive. (If yes, and a copy is available, attach a copy to form.)
Brief History of mental illness (age of onset, prior 5150’s, prior hospitalizations, history of violence, history of self harm, history of unstable living situations)(Attach additional pages, if necessary):
Age illness began ______________
Prior 5150’s? |
No |
Yes |
If yes, how many _______________ |
||
Prior hospitalizations? |
No Yes |
|
If yes, how many _______________
Page 1 of 3
AB 1424 form rev. 10/2006
Does consumer have a conservator? No Yes Don’t know
If yes, name _____________________________________________ phone: ___________________
Do you know consumer’s diagnosis? No Yes Don’t know
Please explain:
_____________________________________________________________________________
Do you know of any substance abuse problem? No Yes Don’t know
Please explain:
_____________________________________________________________________________
Current medications (Psychiatric and Medical) _________________________________________
Names:
__________________________________________________________________________________
Medications consumer has responded well to:
__________________________________________________________________________________
Medications that did not work for the consumer:
__________________________________________________________________________________
Treating Psychiatrist and Case Manager
Psychiatrist ______________________________________________ Phone ____________________
Case Manager ____________________________________________ Phone ___________________
Medical
Significant Medical Conditions: _________________________________________________________
Allergies to Medications, Food, Chemicals, Other: __________________________________________
Primary Care Physician: ____________________________________ Phone: ___________________
Current Living Situation |
|
|
|
|
Family |
|
Independent |
|
Homeless |
|
Transitional |
|
Board & Care |
|
SIL |
Is this a stable situation for consumer?
Information submitted by
Name (print) ____________________________________ Relationship to consumer ______________
Address ___________________________________________________________________________
(city) |
(state) |
(zip) |
Phone __________________________ |
|
|
Signature _____________________________________________ Date _______________________
A person “shall be liable in a civil action for intentionally giving any statement that he or she knows to be false” {Welfare & Institutions Code, Section 515.05(d)}.
Page 2 of 3
AB 1424 form rev. 10/2006
Alameda County Behavioral Health Care Services
Historical Information Provided by Family Member or Other Interested Party
Name of Consumer ________________________ Date of Birth __________ Phone _____________
History of Consumer’s Decompensation
Please check off symptoms or behaviors that consumer has had in past when decompensating and indicate which ones you are observing with the consumer now.
Symptom or Behavior |
|
Past |
|
Now |
suicide gesture/attempts
suicidal statements
thinking about suicide
cutting on self
harming self
sleeping too much
not sleeping
not eating
suspicious (paranoia)
fire setting
aggressive behavior (fighting)
threats
irrational thought patterns (not making sense)
destruction of property
sexual harassing/preoccupation
hearing voices
lack of motivation
anxious and fearful
avoiding others or isolating
talking too much or too fast
argumentative
Symptom or Behavior |
|
Past |
|
Now |
|
|
|
|
|
|
|
weepiness
being too quiet
expressing feelings of worthlessness
afraid to leave the house
giving away belongings
increased irritability and/or negativity
laughing inappropriately
stopping medication
repetitive behaviors
forgetfulness
not paying bills
taking more medication than prescribed
failing to go to doctor’s appointments
spending too much money
poor hygiene
overeating
impulsive behavior
not answering phone/turning off phone machine
talking to self
substance abuse
homelessness or running away
Please describe recent history and behaviors that indicate dangerousness to self, dangerousness to others and/or make the consumer unable to care for him/herself.
Page 3 of 3
AB 1424 form rev. 10/2006