Ab 1424 Form – Fill Out and Use This PDF

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____________________________

Medi-Cal: ฀ Yes ฀ No Medicare: ฀ Yes ฀ No

Name of Private Medical Insurer ______________________________________________________

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 _______________

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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)}.

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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.

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.

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AB 1424 form rev. 10/2006