Colorado Post Admission Level 1 Passr Form – Fill Out and Use This PDF

First Name:

Middle Initial:

Last Name:

Mailing Address:

City:

State:

Zip:

Phone:

Social Security #:

-

-

Date of Birth:

/

/

Gender: c Male c Female Race: c Caucasian c African American c Asian c Hispanic c Other:

Current Location: c*Medical Facility c*Psychiatric Facility c *Nursing Facility c Community c Other:

*Provide Admission Date:

Receiving Nursing Facility:

Receiving Nursing Facility Address:

City:

State:

Zip:

Payment Method: c Medicare c Private Pay c Medicaid c Medicaid Pending c Medicaid #

c Hospice c PACE c 30 Day PACE Respite

** Provide ULTC Scores if Medicaid or Medicaid Pending:

Bathing

Dressing

Toileting

Mobility

Transfer

Eating

Supervision Behaviors

Supervision Memory/Cognition

Section I: MENTAL ILLNESS

1. Does the individual have any of the

2.

Does the individual have any of the

3. Does the individual have a diagnosis of

following Major Mental Illnesses

following mental disorders?

a mental disorder that is not listed in

(MMI)?

c No

#1 or #2? (do not list dementia here)

c No

c Suspected: One or more of the

c No

c Suspected: One or more of the

following diagnosis is suspected

c Yes (if yes, enter the diagnosis(es)

following diagnoses is suspected

(check all that apply)

below):

(check all that apply)

c Yes: (check all that apply)

c Yes: (check all that apply)

c Personality Disorder

c Diagnosis 1:

c Schizophrenia

c Anxiety Disorder

c Diagnosis 2:

c Schizoaffective Disorder

c Panic Disorder

c Major Depression

c Depression (mild or situational)

c Psychotic/Delusional Disorder

(provide GDS Score:

)

c Bipolar Disorder (manic depression)

c Paranoid Disorder

Section II: SYMPTOMS

4. Interpersonal—Currently or within the past 6 months, has the

5. Concentration/Task related symptoms—Currently or within

individual exhibited interpersonal symptoms or behaviors [not

the past 6 months, has the individual exhibited any of the

due to a medical condition]?: c No c Yes

following symptoms or behaviors [not due to a medical

c Serious difficulty interacting with others

condition]? c No

c Yes

c Altercations, evictions, or unstable employment

c Serious difficulty completing tasks that she/he should be

c Frequently isolated or avoided others or exhibited signs

capable of completing

suggesting severe anxiety or fear of strangers

c Required assistance with tasks for which she/he should be

capable

c Substantial errors with tasks in which she/he completes

Adaptation to change —Currently or within the past 6 months, has the individual exhibited any symptoms in #6, 7 or 8 related to

adapting to change? c No (proceed to Section III) c Yes (complete 6-8)

6. c Self injurious or self

7. c Severe appetite disturbance

8.

c Other major mental health symptoms (this may include

mutilation

c Hallucinations or delusions

recent symptoms) that have emerged or worsened as a result

c Suicidal talk

c Serious loss of interest in things

of recent life changes as well as ongoing symptoms.

c History of suicide

c Excessive tearfulness

Describe symptoms:

attempt or gestures

c Excessive irritability

c Physical violence

c Physical threats (no potential for

c Physical threats (with

harm)

potential for harm)

GDS Score:

(if any areas in #7

are marked)

Patient Last Name:

Patient First Name:

Section III: HISTORY OF PSYCHIATRIC TREATMENT

9. Currently or within the past 2 years , has the individual

10. Currently or within the past 2 years, has the individual

received any of the followingmental health services?

experienced significant life disruption because of mental health

c No

symptoms? c No c Yes (check all that apply):

c Yes (the individual has received the following service[s]):

c Legal intervention due to mental health symptoms

c Inpatient psychiatric hospitalization (if yes, provide

(date:

)

date:

)

c Housing change because of mental illness

c Partial

hospitalization/ day treatment (if yes, provide

(date:

)

date:

)

c Suicide attempt or ideation (date[s]:

)

cResidential treatment (if yes, provide date:

)

c Other:

(date:

)

c Other:

(if yes,

provide date:

)

11.

Has the individual had a recent psychiatric/behavioral evaluation?

c No c Yes (date:

)

Section IV: DEMENTIA

12.

Does theindividual have a diagnosis

13. If yes to #12, is corroborative testing or other information available to verify the presence

of dementia or Alzheimer’s disease?

or progression of the dementia?

c No (proceed to 15) c Yes

c No c Yes (check all that apply)

c Dementia work up c Comprehensive Mental Status Exam

c Other (specify):

Medication

Dosage MG/Day

Refer to Beer’s List

Does dosage exceed Beer’s List? cNo cYes

Does dosage exceed Beer’s List? cNo cYes

Does dosage exceed Beer’s List? cNo cYes

16.

Does the individual have a diagnosis of mental retardation

17.

Does the individual have any history of MR or DD? c No c Yes

(MR) or developmental disability (DD)? c No c Yes

18.

Is there presenting evidence of a cognitive or behavioral

19.

Has the individual ever received services from an agency that

impairment prior to age 22 or suspicion of MR condition that

serves people affected by MR/DD? c No

occurred prior to age 18? c No c Yes

c Yes—agency:

Patient Last Name:

Patient First Name:

Guardian Last Name:

First Name:

Street:

City:

State:

Zip:

Print Name:

Signature:

Date:

/

/

Agency/Facility:

Phone:

Fax:

Level I Approved:

PASRR Authorization #:

c No MMI/DD

c Follow-up next qtr.

c PACE Respite

c 30 Day Exemption

c Hospice

c Convalescent Care

c Terminal

c Severity of Illness

c Provisional-Out of state Adm.

c Provisional-Emergency Adm.

Level II Referred:

c MI

c MR/DD

c Dual